Illinois audiogram form 2025

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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.
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.
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.
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.
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.
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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.

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