DVBCADCK ;ALB/GTS-557/THM-AUDIO EXAM ; 5/10/91 9:13 AM
;;2.7;AMIE;;Apr 10, 1995
;
S PG=1,HD91="Department of Veterans Affairs"
S HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1305 Worksheet" S HD7="AUDIO",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,! I '$D(CMBN) W "Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
W !!!!,"Narrative:"
W ?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",!
W ?13,"the use of both pure tone average and speech discrimination",!?13,"inappropriate.",!! I '$D(CMBN) W "A. Audiological history:",!!!!!!!!!!
W $S($D(CMBN):"A. ",1:"B. ") W "Pure tone thresholds at indicated frequencies (air conduction):",!!?16,"dB",?49,"dB",!," ========== RIGHT EAR ========== + ========== LEFT EAR ===========",!
W " A* B C D E A* B C D E",!
W "+------------------------------**+------------------------------**+",!
W "| 500|1000|2000|3000|4000|Average| 500|1000|2000|3000|4000|Average|",!,"+--------------------------------+--------------------------------+",!
W "| | | | | | | | | | | | |",!,"+----+----+----+----+----+-------+----+----+----+----+----+-------+",!!
W "* 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"
W !!!!,$S($D(CMBN):"B. ",1:"C. ") W "Speech recognition score:",!!," 1. Maryland CNC word list _______ % right ear _______ % left ear",!!
W " 2. W-22 word list _______ % right ear _______ % left ear",!!," (Only if specifically requested by the regional office)",!!!! I $Y>58 D HD2
W $S($D(CMBN):"C. ",1:"D. "),"Note whether tinnitus is present and if so, indicate the following:",!!!! S X1=0
F X="Date/circumstance of onset","Unilateral vs bilateral","Constant vs periodic (indicate frequency)","Severity and effect on daily life","Veteran account of loudness/pitch" S X1=X1+1 W ?5,X1,". ",X," -",!!!! I $Y>58 D HD2
K X1,X
W $S($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 -",!!!!!!!
W $S($D(CMBN):"E. ",1:"F. "),"Summary of audiologic test results:",!!!!!!!!
W $S($D(CMBN):"F. ",1:"G. "),"Recommendations/remarks:",!!!!!!!!
W ?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
W !!?22,"Adequated by: ______________________________",!!?30,"Date: _________________________",!
K LN,LN1,LN2
Q
;
HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for "_NAME,!,HD8,!!!
Q
;
SETIOF ; ** Set device control var's
D HOME^%ZIS
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCADCK 3180 printed Apr 09, 2024@20:45:55 Page 2
DVBCADCK ;ALB/GTS-557/THM-AUDIO EXAM ; 5/10/91 9:13 AM
+1 ;;2.7;AMIE;;Apr 10, 1995
+2 ;
+3 SET PG=1
SET HD91="Department of Veterans Affairs"
+4 SET HD9=$SELECT($DATA(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
EN if '$DATA(IOF)
DO SETIOF
if (IOST?1"C-".E)
WRITE @IOF
+1 WRITE !?25,HD91,!?22,"Compensation and Pension Examination",!
WRITE ?33,"# 1305 Worksheet"
SET HD7="AUDIO"
SET HD8="For "_HD7
WRITE !?(40-($LENGTH(HD9)\2)),HD9,!?(40-($LENGTH(HD8)\2)),HD8,!!
+2 WRITE !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!
IF '$DATA(CMBN)
WRITE "Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
+3 WRITE !!!!,"Narrative:"
+4 WRITE ?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",!
+5 WRITE ?13,"the use of both pure tone average and speech discrimination",!?13,"inappropriate.",!!
IF '$DATA(CMBN)
WRITE "A. Audiological history:",!!!!!!!!!!
+6 WRITE $SELECT($DATA(CMBN):"A. ",1:"B. ")
WRITE "Pure tone thresholds at indicated frequencies (air conduction):",!!?16,"dB",?49,"dB",!," ========== RIGHT EAR ========== + ========== LEFT EAR ===========",!
+7 WRITE " A* B C D E A* B C D E",!
+8 WRITE "+------------------------------**+------------------------------**+",!
+9 WRITE "| 500|1000|2000|3000|4000|Average| 500|1000|2000|3000|4000|Average|",!,"+--------------------------------+--------------------------------+",!
+10 WRITE "| | | | | | | | | | | | |",!,"+----+----+----+----+----+-------+----+----+----+----+----+-------+",!!
+11 WRITE "* 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"
+12 WRITE !!!!,$SELECT($DATA(CMBN):"B. ",1:"C. ")
WRITE "Speech recognition score:",!!," 1. Maryland CNC word list _______ % right ear _______ % left ear",!!
+13 WRITE " 2. W-22 word list _______ % right ear _______ % left ear",!!," (Only if specifically requested by the regional office)",!!!!
IF $Y>58
DO HD2
+14 WRITE $SELECT($DATA(CMBN):"C. ",1:"D. "),"Note whether tinnitus is present and if so, indicate the following:",!!!!
SET X1=0
+15 FOR X="Date/circumstance of onset","Unilateral vs bilateral","Constant vs periodic (indicate frequency)","Severity and effect on daily life","Veteran account of loudness/pitch"
SET X1=X1+1
WRITE ?5,X1,". ",X," -",!!!!
IF $Y>58
DO HD2
+16 KILL X1,X
+17 WRITE $SELECT($DATA(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 -",!!!!!!!
+18 WRITE $SELECT($DATA(CMBN):"E. ",1:"F. "),"Summary of audiologic test results:",!!!!!!!!
+19 WRITE $SELECT($DATA(CMBN):"F. ",1:"G. "),"Recommendations/remarks:",!!!!!!!!
+20 WRITE ?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
+21 WRITE !!?22,"Adequated by: ______________________________",!!?30,"Date: _________________________",!
+22 KILL LN,LN1,LN2
+23 QUIT
+24 ;
HD2 SET PG=PG+1
WRITE @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for "_NAME,!,HD8,!!!
+1 QUIT
+2 ;
SETIOF ; ** Set device control var's
+1 DO HOME^%ZIS
+2 QUIT
