MERI-TRP eski |

Patient Info

Patient Name

Patient Phone

Patient Age

Patient ID

Gender*

Female

Male

Diagnosis*

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Side*

Left

Right

Surgery Date*

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Doctor Info

Doctor Name

Doctor E-mail

Audiometry

	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
Left	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
Right	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT

Tympanometry - Left

Tympanometry - Right

Other Evaluation Notes

Radiologic or audiovestibular

Only English Characters

Post-operative Findings (Not mandatory)

Follow-up Date

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Follow-up Time

Months

Postoperative Notes

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	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
Left	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT
Right	PTA - Air Conduction	PTA - Bone Conduction	Air-Bone Gap	Speech Discrimination	SRT

Graft Status

Extrusion

Middle Ear Fluid

Cholesteatoma

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Patient Info

Doctor Info

MERI score

Post-operative Findings (Not mandatory)

Terms and Conditions

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