Hearing Impairment Calculation Worksheet

A.N.S.I. 1969 · F252-007-000 · Auto-calculates as you enter audiogram values

Patient Name

Date

Date of Audiogram

Hours Since Last Exposure

X Left Ear

Hz	dB Level
500
1000
2000
3000

Total (sum of 4 freqs) —

Avg threshold (÷ 4) —

Less threshold fence (− 25) —

        Monaural loss (× 1.5)
        —
      

Tinnitus rating (0–5%)

Total monaural hearing loss —

⚠ Monaural loss is 0% — stop here

O Right Ear

Hz	dB Level
500
1000
2000
3000

Total (sum of 4 freqs) —

Avg threshold (÷ 4) —

Less threshold fence (− 25) —

        Monaural loss (× 1.5)
        —
      

Tinnitus rating (0–5%)

Total monaural hearing loss —

⚠ Monaural loss is 0% — stop here

Combined (Binaural) Hearing Loss

      ([ better ear % × 5 ] + [ worse ear % ]) ÷ 6  =  % binaural loss
    

Better ear (%)

— × 5 = —

Worse ear (%) —

Sub-total —

Sub-total ÷ 6 —

Binaural Hearing Loss

—

Note: Hours since last noise exposure must be more than 14. Stop calculation if either monaural hearing loss percentage is zero. Maximum monaural loss is capped at 100%. Tinnitus rating: 0–5%. This calculator follows the ANSI 1969 standard as per Form F252-007-000.