Name: Date:

Age: Case No.:

Frequency
125 250 500 750 1000 1500 2000 3000 4000 6000 8000
AC, masked if necessary Right ear 0 20 30 40 40 40 40 40 40 60 70
Left Ear 0 0 0 0 0 0 0 0 0 0 0

AC, not masked (shadow) Right ear 10 10 10 10 10 10 10 10 10 10 10

Left Ear 10 10 10 10 10 10 10 10 10 10 10

BC, not masked Right ear 20 20 20 20 20 20 20 20 20 20 20

Left Ear 20 20 20 20 20 20 20 20 20 20 20

BC, masked Right ear 30 30 30 30 30 30 30 30 30 30 30

Left Ear 30 30 30 30 30 30 30 30 30 30 30

ULL Right ear 90 90 90 90 90 90 90 90 90 90 90

Left Ear 90 90 90 90 90 90 90 90 90 90 90

Audiometer:

Tester:
 University of Manchester HCD

PURE TONE AUDIOGRAM

Name: 0 Age: 0 Date: 30-Dec-99 Case No.: 0

-10 -10

Hearing Level (dB)

Hearing Level (dB)

0 0

10 10

20 20

30 30

40 40

50 50

60 60

70 70

80 80

90 90

100 100

110 110

120 250 120 125 250 500 1000 2000 4000 8000
125 500 1000 2000 4000 8000
Frequency (Hz) Frequency (Hz)

Masking Details: Masking Details:

Right Left

Air conduction, masked if necessary

Air conduction, not masked (shadow point)

Bone conduction, not masked

Bone conduction, masked

Uncomfortable loudness level

Remarks:

Audiometer: Calibration standards AC BC Tested By:

Dr. Richard J Baker richard.baker@man.ac.uk