HEARING IMPAIRMENTS TREATING PHYSICIAN DATA SHEET/Impact Disability Law

HEARING IMPAIRMENTS TREATING PHYSICIAN DATA SHEET
“A.S.” means left ear.
“A.D.” means right ear.
“dB” means decibels.
I. Does the person have a hearing impairment?

YesNoUnknown
Date diagnosed

MonthDayYear
Date
A. Significant hearing loss right ear:

YesNoUnknown
B. Significant hearing loss left ear:

YesNoUnknown
II. Describe type of hearing loss (sensorineural, otosclerosis, otitis media, etc.):
III. Treatment and response
A. Surgery:

YesNoUnknown
Please briefly describe surgery and attach operative note.
File Upload

Cancelof
B. Medication:

YesNoUnknown
Please list drugs prescribed for this disorder, including dosage and schedule, and any reported side-effects.
C. Aided hearing?

YesNoUnknown
Type:

A.D.A.S.Cochlear implant
If unable to use aided hearing, please explain.
IV. Audiometric testing

(if done, please attach copy)
1. Unaided air conduction threshold sensitivity: average of 500, 1000, 2000 Hz
A.D. (dB)
A.S. (dB)
1a. Unaided bone conduction threshold sensitivity: average of 500, 1000, 2000 Hz
A.D. (dB)
A.S. (dB)
2. Aided air conduction threshold sensitivity: average of 500, 1000, 2000 Hz
A.D. (dB)
A.S. (dB)
2a. Aided bone conduction threshold sensitivity: average of 500, 1000, 2000 Hz
A.D. (dB)
A.S. (dB)
3. Unaided speech discrimination
A.D. (percent)
A.S. (percent)
4. Aided speech discrimination (where possible)
A.D. (percent)
A.S. (percent)
V. Specific residual functional capacities and limitations.
A. Can understand most speech in a quiet environment.

YesNoUnknown
B. Can understand most speech in a noisy environment.

YesNoUnknown
C. Can effectively use a telephone with aids.

YesNoUnknown
Please use this space to discuss any specific capacities or limitations (related to hearing) you think may be relevant to a work environment.
VI. Additional Physician Comments:
Physician’s Name

First NameLast Name
Physician’s Signature (no name stamps)

Clear
Date

MonthDayYear
Date
Should be Empty:

HEARING IMPAIRMENTS TREATING PHYSICIAN DATA SHEET

III. Treatment and response

IV. Audiometric testing

V. Specific residual functional capacities and limitations.