15.10 Buletin Analize Medicale Audio Gram A
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Judeţul…………………………….. Localitatea………………………… Unitatea sanitară…………………..
BULETIN DE ANALIZE MEDICALE NR…………. AUDIOGRAMĂ CNP Data a a a a
l l
z z
Numele………………………………..prenumele…………………………………….. Sexul M ; vârsta……………………….
F Domiciliul: judeţul………………………………………localitatea………………………. Str…………………………………………………………………………………………… Ocupaţia :……………………………………………locul de muncă…….………………… Întrep / inst…………………………………………………………………………………… Trimis de : ……………………………………………………………………………………
REZULTATUL :
Faţă
15.10; A5; t2
← Pierdere auditivă
continuare – 125
250
125
250
-10
500 1000 1500
2000 4000 8000 Hz 3000 6000 10000
0 10 20 30 40 50 60 70 80 90 100 110
Norma -10 0 10 20 30 40 50 60 70 80 90 100 110
← Pierdere auditivă
URECHEA STÂNGĂ -10 0 10 20 30 40 50 60 70 80 90 100 110
500 1000 1500
2000 4000 8000 Hz 3000 6000 10000
Norma -10 0 10 20 30 40 50 60 70 80 90 100 110
URECHEA DREAPTĂ
Concluzii :……………………………………………………………………………………… …………………………………………………………………………………………………. Semnătura şi parafa medicului, ……………………………………………….
BULETIN DE ANALIZE MEDICALE NR…………. AUDIOGRAMĂ CNP Data a a a a
l l
z z
Numele………………………………..prenumele…………………………………….. Sexul M ; vârsta……………………….
F Domiciliul: judeţul………………………………………localitatea………………………. Str…………………………………………………………………………………………… Ocupaţia :……………………………………………locul de muncă…….………………… Întrep / inst…………………………………………………………………………………… Trimis de : ……………………………………………………………………………………
REZULTATUL :
Faţă
15.10; A5; t2
← Pierdere auditivă
continuare – 125
250
125
250
-10
500 1000 1500
2000 4000 8000 Hz 3000 6000 10000
0 10 20 30 40 50 60 70 80 90 100 110
Norma -10 0 10 20 30 40 50 60 70 80 90 100 110
← Pierdere auditivă
URECHEA STÂNGĂ -10 0 10 20 30 40 50 60 70 80 90 100 110
500 1000 1500
2000 4000 8000 Hz 3000 6000 10000
Norma -10 0 10 20 30 40 50 60 70 80 90 100 110
URECHEA DREAPTĂ
Concluzii :……………………………………………………………………………………… …………………………………………………………………………………………………. Semnătura şi parafa medicului, ……………………………………………….
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