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  • 2 Borang Saringan Pendengaran Rev 3 - 0

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    baanu1988
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    This document appears to be a hearing screening form in Malay. It collects information about a patient's name, address, contact details and occupation. It documents the results of an otoscopy exam of both ears, an oto-acoustic emissions screening test, a hearing screening test, tympanometry and a pure tone audiometry test measuring hearing levels at different frequencies in both ears with and without headphones. Space is provided for notes from the audiologist or audiometrist performing the screening.

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    2 Borang Saringan Pendengaran Rev 3_0

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    This document appears to be a hearing screening form in Malay. It collects information about a patient's name, address, contact details and occupation. It documents the results of an otoscopy exam of both ears, an oto-acoustic emissions screening test, a hearing screening test, tympanometry and a pure tone audiometry test measuring hearing levels at different frequencies in both ears with and without headphones. Space is provided for notes from the audiologist or audiometrist performing the screening.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    6 views2 pages

    2 Borang Saringan Pendengaran Rev 3 - 0

    Uploaded by

    baanu1988
    This document appears to be a hearing screening form in Malay. It collects information about a patient's name, address, contact details and occupation. It documents the results of an otoscopy exam of both ears, an oto-acoustic emissions screening test, a hearing screening test, tympanometry and a pure tone audiometry test measuring hearing levels at different frequencies in both ears with and without headphones. Space is provided for notes from the audiologist or audiometrist performing the screening.

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    © All Rights Reserved
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    of 2

    Tarikh : ____/_____/_______

    BORANG SARINGAN PENDENGARAN

    Nama : ___________________________________ No. K/P : ___________________________________

    Alamat :______________________________________________________________________________
    ______________________________________________________________________________
    No Tel: __________________________________ Pekerjaaan : _________________________________
    1) Pemeriksaan Otoskopi
    RIGHT LEFT

    Wax Clear/Partial/ Blocked Clear/Partial/ Blocked

    Discharge Yes/No Yes/No

    Tympanic Membrane Intact/Perforated Intact/Perforated

    2)Oto-acoustic Emission Screening (OE) : PASS / FAIL (………………………………………………………………)


    3) Hearing Screening by HEAR CHECK NAVIGATOR : PASS / FAIL (………………………………………………….)
    4) Tympanometry : Type A / Type B / Type C
    5) Pure Tone Audiometry (PTA)
    250 Hz 500 Hz 1000 HZ 2000 HZ 4000 Hz 8000 Hz

    AC (RIGHT)

    BC

    AC (LEFT)

    BC

    Catatan :…………………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………………………………………….

    Audiologist/ Audiometris
    ASHS-F-019 Rev: 00
    ________________________________
    ( )
    ---------------------------------------------------------------------------------------------------------------------------------------------------

    BORANG SARINGAN PENDENGARAN Tarikh : ____/_____/_______

    Nama : ___________________________________ No. K/P : ___________________________________


    Alamat :______________________________________________________________________________
    ______________________________________________________________________________
    No Tel: __________________________________ Pekerjaaan : _________________________________
    1) Pemeriksaan Otoskopi
    KANAN KIRI

    Wax Clear/Partial/ Blocked Clear/Partial/ Blocked

    Discharge Yes/No Yes/No

    Tympanic Membrane Intact/Perforated Intact/Perforated

    2)Oto-acoustic Emission Screening (OE) : PASS / FAIL (………………………………………………………………)


    3) Hearing Screening by HEAR CHECK NAVIGATOR : PASS / FAIL (………………………………………………….)
    4) Tympanometry : Type A / Type B / Type C
    5) Pure Tone Audiometry (PTA)
    250 Hz 500 Hz 1000 HZ 2000 HZ 4000 Hz 8000 Hz
    AC (RIGHT)

    BC

    AC (LEFT)

    BC

    Catatan :…………………………………………………………………………………………………………………………………………………..
    ………………………………………………………………………………………………………………………………………………………………….
    ………………………………………………………………………………………………………………………………………………………………….

    Audiologist/ Audiometris

    ________________________________
    ASHS-F-019 Rev: 00
    ( )

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