NU-6 LIST 1A NU-6 LIST 2A SOUND FIELD SCREENING-QUIET ...

1 Check ( ) incorrect responses. NU-6 LIST 1A NU-6 LIST 2A. SOUND FIELD SCREENING-QUIET SOUND FIELD screening -NOISE. laud _____ goose_____ raise _____ pick _____ loaf _____ soap _____. boat _____ whip _____ third _____ room _____ dab _____ young _____. pool _____ tough_____ gap _____ nice _____ numb _____ ton _____. nag _____ puff _____ fat _____ said _____ juice _____ keg _____. limb _____ keen _____ met _____ fail _____ chief _____ calm _____. shout _____ death_____ jar _____ south _____ merge _____ tool _____. sub _____ sell _____ door _____ white _____ wag _____ pike _____. vine _____ take _____ keep _____ rain _____. dime _____ fall _____ dead _____ witch _____.

2 _____ dB SPL Number Correct _____ x 4 = _____ % _____ dB SPL Number Correct _____ x 4 = _____ %. NU-6 LIST 1A NU-6 LIST 2A NU-6 LIST 3A. laud _____ love _____ pick _____ mil _____ base _____ gun _____. boat _____ sure _____ room _____ hush _____ mess _____ jug _____. pool _____ knock _____ nice _____ shack _____ cause _____ sheep _____. nag _____ choice _____ said _____ read _____ mop _____ five _____. limb _____ hash _____ fail _____ rot _____ good _____ rush _____. shout _____ lot _____ south _____ hate _____ luck _____ rat _____. sub _____ raid _____ white _____ live _____ walk _____ void _____. vine _____ hurl _____ keep _____ book _____ youth _____ wire _____.

3 Dime _____ moon _____ dead _____ voice _____ pain _____ half _____. goose_____ page _____ loaf _____ gaze _____ date _____ note _____. whip _____ yes _____ dab _____ pad _____ pearl _____ when _____. tough _____ reach _____ numb _____ thought _____ search _____ name _____. puff _____ king _____ juice _____ bought _____ ditch _____ thin _____. keen _____ home _____ chief _____ turn _____ talk _____ tell _____. death _____ rag _____ merge _____ chair _____ ring _____ bar _____. sell _____ which _____ wag _____ lore _____ germ _____ mouse _____. take _____ week _____ rain _____ bite _____ life _____ hire _____. fall _____ size _____ witch _____ haze _____ team _____ cab _____.

4 Raise _____ mode _____ soap _____ match _____ lid _____ hit _____. third _____ bean _____ young _____ learn _____ pole _____ chat _____. gap _____ tip _____ ton _____ shawl _____ road _____ phone _____. fat _____ chalk _____ keg _____ deep _____ shall _____ soup _____. met _____ jail _____ calm _____ gin _____ late _____ dodge _____. jar _____ burn _____ tool _____ goal _____ cheek _____ seize _____. door _____ kite _____ pike _____ far _____ beg _____ cool _____. _____ dB HL Right Left _____ dB HL Right Left _____ dB HL Right Left Number Correct ____ Binaural Number Correct ____ Binaural Number Correct ____ Binaural x 2 = _____ % Quiet Noise x 2 = _____ % Quiet Noise x 2 = _____ % Quiet Noise Maskung Level Tape CD Maskung Level Tape CD Maskung Level Tape CD.

5 If Used _____ Live Voice If Used _____ Live Voice If Used _____ Live Voice ADDITIONAL INFORMATION: _____. _____. _____. _____. _____. 2014, Beltone 5201627 Rev. D 06/14. CONFIDENTIAL CASE HISTORY. NAME _____. DATE _____. NAME _____. STREET _____. STATE OR ZIP OR. CITY _____ PROVINCE _____ POSTAL CODE _____. PHONE ( _____ ) _____ DATE OF BIRTH _____. (PAST/PRESENT). SOCIAL SECURITY _____ OCCUPATION _____. ID NUMBER OR. INSURANCE CARRIER _____ INSURANCE POLICY NO. _____. OBSERVING PARTY _____. EMAIL ADDRESS _____. _____. BELTONE AUDIOLOGIST OR. HEARING CARE PRACTITIONER. _____ _____. STATE OR PROVINCIAL LICENSE NUMBER. AUTHORIZED BELTONE DISPENSER. DM TM TV NP YP RA REF PP OTHER _____.

6 NAME _____ DATE _____. Results of ear inspection _____. UNAIDED SOUND FIELD screening _____ dB SPL Level Used _____ % Correct in Noise _____ % Correct in Quiet BELTONE AUDIOGRAM ANSI 1987. FREQUENCY IN HERTZ (Hz) STANDARD. 125 250 500 1000 2000 4000 8000. 0 0. 10 10. 20 20. HEARING THRESHOLD LEVEL IN dB. 30 30. 40 40. 50 50. 60 60. 70 70. 80 80. 90 90. 100 100. 110 110. RT. RT. RT. RT. RT. RT. Masking Level Used LT. LT. LT. LT. LT. LT. 250 500 1000 2000 4000 8000. RT. RT. RT. RT. RT. RT. Frequency Specific LDLs (HL) LT. LT. LT. LT. LT. LT. SPEECH TEST RESULTS DISCRIMINATION TEST RESULTS. NU-6 MRT EAR. AVE. (HTL) PRESENTATION. PURE-TONE % CORRECT LEVEL. NOISE QUIET SRT (HTL) LDL (HTL) MCL (HTL).

7 MASKING RIGHT. RIGHT LEFT LEFT. L R L R. BINAURAL. SYMBOLS. RIGHT EAR LEFT EAR NO RESPONSE NOTE: The light lines represent the vertical MODALITY (RED) (BLUE) RIGHT EAR LEFT EAR axis of an audiogram. Symbols indicating AIR CONDUCTION NO RESPONSE, should not be connected UNMASKED. MASKED. to any other symbols. These symbols have been approved by ASHA, AAO-HNS, and IHS. BONE CONDUCTION. UNMASKED. MASKED. CASE HISTORY. YES NO Visible congenital or trumatic deformity of the ear YES NO History of active drainage from the ear within the previous 90 days YES NO History of sudden or rapidly progressive hearing loss within the previous 90 days YES NO Acute or chronic dizziness YES NO Unilateral hearing loss of sudden or recent onset within the previous 90 days YES NO Audiometric air-bone gap equal to or greater than 15 dB (ANSI) at 500 Hz, 1000 Hz, and 2000 Hz YES NO Visible evidence of cerumen accumulation or a foreign body in the ear canal YES NO Pain in the ear FAMILY PHYSICIAN: _____.

8 When did you first notice the problem with your hearing and understanding? _____. What brought this to your attention? _____. What do you believe caused your hearing problem? _____. Did the problem come on suddenly or gradually? _____. Has this loss affected your voice or speech yet? _____. Have you noticed any ringing or other unusual noises in your ears? _____. Who else in your family has a hearing problem? _____. What experience have you ever had with hearing instruments? _____. How well do you understand on the telephone? _____. Which ear do you use? _____. Do you have trouble hearing the doorbell or telephone ring? _____. Who do you hear better? Men _____ Women _____.

9 How well do you understand your children or grandchildren? _____. Do you have trouble understanding when there are 2 or 3 people talking at the same time? _____. Does noise in the background interfere with your understanding conversation? _____. How does this make you feel? _____. When you go to church, meeting or social gatherings, how well do you understand everything that is said? _____. Has this caused you to stop attending any of these? _____. Are you able to understand conversation around the dinner table? _____. Do others complain that the television is too loud? _____. What other difficulty does your hearing problem cause you at home? _____. What difficulty does your hearing problem cause you at work?

10 _____. Do you have trouble understanding conversation while riding in the car? _____. Do you feel safe with your ability to hear sirens and turn signals while driving or riding in the car? _____. Do you travel often? _____. In which one situation would you like to hear and understand better? _____. _____. If properly fitted Beltone hearing instruments would help you hear and understand better, would you accept this help? _____. Medications, if taking any: _____. Do you have any allergies? _____. Comments: _____. _____.