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MEEI Hearing Aid Center Referral for Audiologic Services
Note: This form is for copying and faxing. Do not send online.
Boston - Audiology Clinic: FAX 617-573-3023
Boston - Hearing Aid and Cochlear Implant Center: FAX 617-573-3233
Stoneham: F AX 617-573-5644
Newton-Wellesley: FAX 671-527-8326
Patient Name_____________________________________________________
Patient Address_____________________________________________________
Patient D.O.B._____________________________________________________
AUDIOLOGIC EVALUATION
Consultation / full audiogram
Cochlear implant evaluation*
Air and bone conduction only
Functional screening
Air, bone and speech audiometry only
Water precaution earmolds
Tympanometry
Other___________________________________
ELECTROPHYSIOLOGIC EVALUATION
HEARING AIDS / REHABILITATION
Diagnostic evoked response audiometry* (ABR)
Threshold evoked response audiometry
Electrocochleography* (EcoG)
Hearing aid check
Evoked otoacoustic emissions (OAE)
Hearing aid consultation*
Vestibular Myogenic Potentials (VEMP)
Cochlear implant consultation*
Facial nerve evaluation (ENoG)
Aural rehabilitation:
communication therapy,assistive devices, support service information, etc.
Other___________________________________
Other__________________________________
* If recent audiogram is not available, a hearing test will be performed
REASON FOR TEST / SYMPTOMS*
*Rank By Order of Importance
Blockage / aural fullness
STATUS
(where applicable)
Decreased hearing
Dizziness / vertigo
Initial evaluation
Facial weakness / paralysis
Recent onset of symptoms
Impacted cerumen
Monitoring / Follow-up
Inflammation of ear
Pre-op
Meniere's disease / endolymphatic hydrops
Post-op
Neurological evaluation
Medico-legal considerations
Nystagmus
Otalgia
Otitis
Otorrhea
Speech / language delay
Sudden hearing loss
Symptoms associated with ototoxic drugs
Tinnitus
Unilateral / asymmetric hearing loss
Other_______________________________
OTOLOGIC EXAMINATION
KNOWN DIAGNOSES
Signature
Date
MEDICAL CLEARANCE FOR A HEARING AID
The above named patient's hearing loss has been medically evaluated and the patient may be considered a candidate for a hearing aid. This does not constitute a recommendation for a hearing aid, only that there are no medical contraindications to hearing aid use.
Signature
Date
date of form: May 7, 2003
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