Prompt: !?25,HD91,!?22,"Compensation and Pension Examination",!
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Prompt: ?33,"# 1305 Worksheet"
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Prompt: ?33,"# 1305 Worksheet"
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Prompt: "Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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Prompt: !!!!,"Narrative:"
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Prompt: ?13,"When only pure tone results should be used to evaluate",!?13,"hearing loss, the Chief of the Audiology Clinic should",!?13,"certify that language difficulties or other problems make",!
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Prompt: "A. Audiological history:",!!!!!!!!!!
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Prompt: $S($D(CMBN):"A. ",1:"B. ")
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Prompt: "Pure tone thresholds at indicated frequencies (air conduction):",!!?16,"dB",?49,"dB",!," ========== RIGHT EAR ========== + ========== LEFT EAR ===========",!
Prompt: "* The pure tone threshold at 500 Hz is not currently used for evaluation",!,"purposes but is used in determining whether or not a ratable hearing",!,"loss exists.",!!,"** - average of B, C, D, and E"
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Prompt: !!!!,$S($D(CMBN):"B. ",1:"C. ")
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Prompt: "Speech recognition score:",!!," 1. Maryland CNC word list _______ % right ear _______ % left ear",!!
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Prompt: " 2. W-22 word list _______ % right ear _______ % left ear",!!," (Only if specifically requested by the regional office)",!!!!
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Prompt: $S($D(CMBN):"C. ",1:"D. "),"Note whether tinnitus is present and if so, indicate the following:",!!!!
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Prompt: ?5,X1,". ",X," -",!!!!
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Prompt: $S($D(CMBN):"D. ",1:"E. "),"Note whether audiologic results indicate an ear or hearing problem",!,"that requires medical follow-up or a problem, which, if treated, may",!,"cause a change in hearing threshold levels -",!!!!!!!
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Prompt: $S($D(CMBN):"E. ",1:"F. "),"Summary of audiologic test results:",!!!!!!!!