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Illinois audiogram form 2025

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The document is an audiogram form used by the Illinois Department of Public Health for hearing screening. It collects personal information about the individual being tested, including their name, birth date, and contact details. The form includes sections for recording hearing test results at various frequencies in hertz and decibels, as well as notes on the testing environment and reliability of responses. It outlines criteria for referral based on the test results and requires signatures for medical or educational referrals.

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Click ‘Get Form’ to open the Illinois Audiogram form in our editor.
Begin by entering the date and test number at the top of the form. This information is crucial for record-keeping.
Fill in the personal details including the name, birth date, sex, and grade of the individual being tested. Ensure accuracy as this data is essential for identification.
Provide parent or guardian information along with their contact number and address. This section helps in case follow-up communication is needed.
In the frequency section, input the screening thresholds in decibels for each frequency listed (250 Hz to 8000 Hz). Use our platform’s tools to easily navigate through these fields.
Record audiometer details and plot air conduction results for both ears using designated symbols (red for right ear, blue for left ear).
Indicate test environment conditions and reliability of responses by checking appropriate boxes.
Complete referral criteria if applicable, ensuring all necessary signatures are included before submission.

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How do I get a copy of my audiogram?

After your visit to a hearing center, they should provide you with a report of your visit. If not included with the report, request a copy of your audiometric test results.

How do I document hearing screening results?

Hearing tests check a persons ability to hear the loudness and pitch of sounds. The results are charted on a graph (audiogram) to help pinpoint the severity and causes of hearing problems. Tests include pure tone audiometry, using an audiometer, and speech discrimination tests.

How to complete a hearing screening?

3:26 7:01 But keep raising your hand when you hear the beep. Continue on with the screening tones. StartingMoreBut keep raising your hand when you hear the beep. Continue on with the screening tones. Starting with the right ear turn the dial to 20 decibels.

What is a passing score on a hearing test?

Document each frequency screened in a manner that indicates the decibel it was screened at and whether the result was a PASS or REFER. Use consistent notations with a key indicating which symbols or words denote PASS and REFER so that results are clear to caregivers/guardians and providers.

Is a hearing test and audiogram the same thing?

The audiogram is a graph showing the results of a pure-tone hearing test. It will show how loud sounds need to be at different frequencies for you to hear them. The audiogram shows the type, degree, and configuration of hearing loss.

How do I fill out a hearing test form?

Fill in the patients personal information such as name, age, and contact details at the top of the form. Indicate the date of the screening on the designated line. Provide information regarding the patients medical history, particularly any previous hearing issues.

Illinois audiogram form 2025

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How to use or fill out Illinois Audiogram Form with DocHub

Complete this form in 5 minutes or less

Got questions?

How do I get a copy of my audiogram?

How do I document hearing screening results?

How to complete a hearing screening?

What is a passing score on a hearing test?

Is a hearing test and audiogram the same thing?

People also ask

How do I fill out a hearing test form?

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Illinois audiogram form 2025

Here's how it works

How to use or fill out Illinois Audiogram Form with DocHub

Complete this form in 5 minutes or less

Got questions?

How do I get a copy of my audiogram?

How do I document hearing screening results?

How to complete a hearing screening?

What is a passing score on a hearing test?

Is a hearing test and audiogram the same thing?

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People also ask

How do I fill out a hearing test form?

Related links

Try more PDF tools