AAO-HNSF Certificate Program for Otolaryngology Personnel

CPOP Testing Log

Sponsoring ENT:

Name:

AC Thresholds R/L 250, 500, 1000, 2000, 3000, 4000, 6000, 8000

BC Thresholds R/L 250, 500, 1000, 2000, 3000, 4000, 6000, 8000

Tympanogram Type

SRT dB

WRS %

Type

Date

Patient Initials

History

Ear Examination

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

30