D AC 125 250 500 1000 2000 3000 4000 6000 8000 BC S AC BC MASKING D AC BC S AC BC
NAMA PASIEN : ________________________ DIAGNOSA :
USIA : ________________________ DEXTRA ________________________________
NO RM : ________________________ SINISTRA _______________________________
Symbol :Air Bone MASKING Air Bone Tanggal Pemeriksaan : ____________________ 125 250 500 1000 2000 3000D : O4000 D : < 6000 D : 8000 ∆ D:[ S :X S :> S :□ S :]
