Patient Last Name Examining Station Patient Number First Exam AUDIOLOGICAL EXAMINATION REPORT First Right ear 500 1000 2000 4000 Claim number Right Ear [] Left Ear [] RIGHT EAR DISCR. Right ear 500 1000 2000 4000 6000 FIGURE 12.C2 AIR CONDUCTION 6000 SPEECH AUDIOMETRY SECT. SPEECH RECEP. THRESHOLD Date of Exam Social Security Number BONE CONDUCTION 500 % [ ] Masking [ ] LEFT EAR DISCRIM. Exam. Audiologist's No. % [ ] Masking [ ] Comments [ Left ear 1000 2000 4000 Referred by [ Reason for referral Examining Audiologist Middle Initial Left ear 500 1000 2000 4000 6000 Next Appt. 6000 ]