RUMAH SAKIT UMUM DAERAH Dr.

ZAINOEL ABIDIN
Jln. Tgk. Daud Beureueh No. 108 Telp (0651) 34562, 34563
Fax (0651) 34566 KodePos 23126
BANDA ACEH

FORM PEMERIKSAAN AUDIOGRAM

IDENTITAS
NAMA/CM :.................................................................
UMUR :.................................................................
JENIS KELAMIN :................................................................
NO. TELP/HP :.................................................................

HASIL PEMERIKSAAN :

FREQUENCY IN HERTZ RIGHT FREQUENCY IN HERTZ LEFT

-20 -20
-10 -10
0 0
10 10
20 20
HEARING LOSS IN DB

HEARING LOSS IN DB

30 30
40 40
50 50
60 60
70 70
80 80
90 90
100 100
110 110
120 120

250 500 750 1K 1K5 2K 3K 4K 6K 8K -20 250 500 750 1K 1K5 2K 3K 4K 6K 8K

SYMBOL TABLE

L R LM RM BL BR BLM BRM

X O □ ∆ > < ] [

KESIMPULAN :

SARAN : Banda Aceh, ......................................

Dokter Pemeriksa