ENT — Hearing Evaluation Template

Visit Information

Date: [Date]
Visit type: Initial evaluation / Follow-up / Hearing aid check / CI evaluation
Referring physician: [Name] / Self-referred

Chief Complaint

[Primary hearing concern]
Duration: [X] months/years
Laterality: Right / Left / Bilateral
Progression: Stable / Progressive / Fluctuating

Hearing History

Hearing Loss Characteristics

Onset: Sudden / Gradual / Congenital
Age at onset: [X] years
Progression: Stable / Slowly progressive / Rapidly progressive / Fluctuating
Laterality: Right / Left / Bilateral — Symmetric / Asymmetric
Perceived severity:

• Quiet conversation: No difficulty / Some difficulty / Significant difficulty
• Group settings: No difficulty / Some difficulty / Significant difficulty
• Telephone: No difficulty / Some difficulty / Significant difficulty
• Television: Normal volume / Increased volume needed

Associated Symptoms

Tinnitus: No / Yes

• Laterality: Right / Left / Bilateral / Central
• Character: [Ringing, buzzing, pulsatile]
• Severity: [1-10, impact on life]

Vertigo: No / Yes — [Description, frequency]
Aural fullness: No / Yes — [R/L]
Otalgia: No / Yes — [R/L]
Otorrhea: No / Yes — [R/L, character]

Hearing Loss Risk Factors

Noise exposure:

• Occupational: No / Yes — [Type, duration, protection]
• Recreational: No / Yes — [Firearms, music, power tools]

Ototoxic medications:

• Aminoglycosides: No / Yes — [Drug, duration]
• Cisplatin: No / Yes
• Loop diuretics: No / Yes
• Aspirin (high dose): No / Yes

Other risk factors:

• Head trauma: No / Yes — [Date, description]
• Meningitis: No / Yes
• Radiation to head/neck: No / Yes
• Autoimmune disease: No / Yes — [Type]
• Diabetes: No / Yes
• Cardiovascular disease: No / Yes

Family History

Hearing loss: No / Yes — [Relationship, age of onset]
Genetic syndrome: No / Yes — [Type]

Current Amplification

Hearing Aids

Current user: No / Yes / Previous user (discontinued)
If current user:

	Right	Left
Brand/Model	[X]	[X]
Style	[BTE/RIC/ITE/ITC/CIC]	[Style]
Age	[X] years	[X] years
Satisfaction	[1-10]	[1-10]

Hours of daily use: [X] hours
Benefit: Significant / Moderate / Minimal / None
Issues: [Feedback, occlusion, dexterity, cosmesis, other]
If previous user (discontinued):
Reason stopped: [Benefit, comfort, cost, cosmesis, other]
Duration of trial: [X] months

Assistive Devices

CROS/BiCROS: No / Yes
FM system: No / Yes
Captioned telephone: No / Yes
Other: [Devices]

Otologic History

Prior ear surgery: None / [Procedure, date, ear]
Ear infections: None / Rare / Frequent — Last: [Date]
PE tubes: None / [Date, complications]
Cholesteatoma: No / Yes — [Treatment]

Physical Examination

Otoscopy

Finding	Right	Left
EAC	Clear / [Cerumen, debris]	[Findings]
TM	Intact, normal / [Findings]	[Findings]
Mobility	Normal / Decreased	Normal / Decreased

Tuning Fork Tests (512 Hz)

Weber: Midline / Lateralizes [R/L]
Rinne R: AC > BC / BC > AC (negative)
Rinne L: AC > BC / BC > AC (negative)

Audiometric Evaluation

Pure Tone Audiometry [Date]

Air Conduction (dB HL):

Frequency	250	500	1000	2000	3000	4000	6000	8000
Right
Left

Bone Conduction (dB HL):

Frequency	500	1000	2000	4000
Right
Left

Summary:

	Right	Left
PTA (500, 1K, 2K)	[X] dB	[X] dB
Type	[Normal/CHL/SNHL/Mixed]	[Type]
Degree	[Normal/Mild/Moderate/Mod-Severe/Severe/Profound]	[Degree]
Configuration	[Flat/sloping/rising/notched/corner]	[Configuration]

Air-bone gap: None / [X] dB at [Frequencies]

Speech Audiometry

	Right	Left	Binaural
SRT	[X] dB	[X] dB
WRS	[X]% at [X] dB	[X]% at [X] dB	[X]%
MCL	[X] dB	[X] dB
UCL	[X] dB	[X] dB

Word recognition interpretation:

• Right: Excellent (90-100%) / Good (80-89%) / Fair (70-79%) / Poor (<70%)
• Left: Excellent / Good / Fair / Poor

Tympanometry

	Right	Left
Type	[A/As/Ad/B/C]	[Type]
Peak pressure	[X] daPa	[X] daPa
Compliance	[X] mL	[X] mL
ECV	[X] mL	[X] mL

Acoustic reflexes:

Stimulus	R ipsi	R contra	L ipsi	L contra
500 Hz	[Present/Absent/Elevated]
1000 Hz
2000 Hz

Additional Testing (if performed)

OAE: [Present/Absent, ear]
ABR: [Findings]
VEMP: [Findings]
Extended high frequency: [Findings]

Functional Assessment

Communication Assessment

Primary communication partner: [Relationship]
Communication difficulties reported:

• [ ] One-on-one conversation
• [ ] Group settings
• [ ] Background noise
• [ ] Telephone
• [ ] Television/media
• [ ] Work/meetings
• [ ] Social isolation

Quality of Life Impact

HHIE-S Score: [X]/40 — [No/Mild/Moderate/Significant] handicap
Other validated measure: [Score, interpretation]
Work impact: None / [Description]
Social impact: None / [Description]
Safety concerns: None / [Doorbells, alarms, traffic]

Assessment

1) [Hearing loss diagnosis]

• Type: [Conductive / Sensorineural / Mixed]
• Degree: [Degree by ear]
• Configuration: [Pattern]
• Symmetry: Symmetric / Asymmetric
• Etiology: [Known/suspected/unknown]

2) [Secondary diagnoses — tinnitus, etc.]
3) [Candidacy assessment]

• Hearing aids: Candidate / Not candidate / [Reason]
• Cochlear implant: Not candidate / Evaluate further / Candidate

Recommendations

Amplification

[ ] Hearing aids recommended

• Style: [BTE/RIC/ITE/ITC/CIC]
• Features: [Directional mics, telecoil, Bluetooth, rechargeable]
• Binaural / Monaural [Ear]
• Trial period: [X] days

[ ] Current hearing aids adequate
[ ] Hearing aid adjustment needed: [Specific changes]
[ ] Hearing aid repair needed
[ ] New hearing aids recommended — Reason: [X]
[ ] CROS/BiCROS system
[ ] Bone conduction device evaluation

Cochlear Implant Evaluation

[ ] Not indicated at this time
[ ] Refer for CI evaluation — Reason: [Criteria met]
[ ] Schedule CI candidacy workup:

• [ ] CT temporal bones
• [ ] MRI IAC
• [ ] CI audiologic evaluation
• [ ] Speech-language evaluation
• [ ] CI team consultation

Medical/Surgical

[ ] No medical treatment indicated
[ ] Medical treatment: [Specify]
[ ] Surgical consultation: [Procedure]
[ ] Further workup:

• [ ] MRI IAC (asymmetric SNHL)
• [ ] Labs (autoimmune, metabolic)
• [ ] Genetic testing
• [ ] Other: [Specify]

Assistive Devices/Rehabilitation

[ ] FM system for [Work/school/worship]
[ ] Captioned telephone
[ ] Alerting devices
[ ] Aural rehabilitation program
[ ] Communication strategies counseling
[ ] Lip-reading classes

Tinnitus Management (if applicable)

[ ] Counseling provided
[ ] Sound therapy
[ ] Hearing aids with tinnitus masking
[ ] Tinnitus retraining therapy referral
[ ] CBT referral

Hearing Conservation

[ ] Noise protection counseling
[ ] Custom ear protection
[ ] Annual monitoring audiogram

Patient Education

• Audiogram results explained
• Hearing loss type and cause discussed
• Treatment options reviewed
• Realistic expectations for amplification
• Communication strategies reviewed
• Hearing protection importance

Follow-up

Return: [X] weeks/months for [Hearing aid fitting, audiogram, etc.]
Annual audiogram: Recommended / [Schedule]
Sooner if: Sudden change, new symptoms

Communication

Report sent to: [Referring physician, PCP]
Hearing aid dispensing: [In-house / Referred to]