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Routine: DVBCQHL2

DVBCQHL2.m

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DVBCQHL2 ;ALB-CIOFO/ECF,SBW - HEARING LOSS QUESTIONNAIRE ;  18/MAY/2011

 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6

 ;

TXT ;

 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 ;; disability benefits.  VA will consider the information you provide on this 

 ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 ;;

 ;; NOTE: This form is only for use by VHA staff or contract examiners. 

 ;;

 ;; This exam is for:

 ;;    ___ Tinnitus only (audiologist or non-audiologist clinician)

 ;;           If this exam is for tinnitus only, complete section 2 only.

 ;;           Otherwise complete entire form.

 ;;    ___ Hearing loss and/or tinnitus (audiologist, performing current exam)

 ;;    ___ Hearing loss and/or tinnitus (audiologist or non-audiologist clinician,

 ;;        using audiology report of record that represents Veteran's current

 ;;        condition)

 ;;           If using audiology report of record, date audiology exam was

 ;;           performed: ______________

 ;;

 ;;                        SECTION 1:  HEARING LOSS (HL)

 ;;

 ;; Note: All testing must be conducted in accordance with the following

 ;; instructions to be valid for VA disability evaluation purposes.

 ;;

 ;; Instructions: An examination of hearing impairment must be conducted by a

 ;; state-licensed audiologist and must include a controlled speech discrimination

 ;; test (specifically, the Maryland CNC recording) and a puretone audiometry

 ;; test in a sound isolated booth that meets American National Standards

 ;; Institute standards (ANSI S3.1.1999 [R2004]) for ambient noise. Measurements

 ;; will be reported at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz.

 ;;

 ;; The examination will include the following tests: Puretone audiometry by

 ;; air conduction at 250, 500, 1000, 2000, 3000, 4000, 6000 Hz and 8000 Hz,

 ;; and by bone conduction at 250, 500, 1000, 2000, 3000, and 4000 Hz, spondee

 ;; thresholds, speech discrimination using the recorded Maryland CNC Test,

 ;; tympanometry and acoustic reflex tests (ipsilateral and contralateral), and,

 ;; when necessary, Stenger tests.  Bone conduction thresholds are measured when

 ;; the air conduction thresholds are poorer than 15 dB HL.  A modified Hughson-

 ;; Westlake procedure will be used with appropriate masking.  A Stenger must

 ;; be administered whenever puretone air conduction thresholds at 500, 1000,

 ;; 2000, 3000, and 4000 Hz differ by 20 dB or more between the two ears.

 ;;

 ;; Maximum speech discrimination will be reported with the 50 word VA approved

 ;; recording of the Maryland CNC test.  The starting presentation level will be

 ;; 40 dB re SRT.  If necessary, the starting level will be adjusted upward to

 ;; obtain a level at least 5 dB above the threshold at 2000 Hz, if not above

 ;; the patient's tolerance level.

 ;;

 ;; The examination will be conducted without the use of hearing aids.  Both

 ;; ears must be examined for hearing impairment even if hearing loss in only

 ;; one ear is at issue.

 ;;

 ;; When speech discrimination is 92% or less, a performance intensity function

 ;; must be obtained.

 ;;

 ;; A comprehensive audiological evaluation should include evaluation results

 ;; for puretone thresholds by air and bone conduction (500-8000 Hz), speech

 ;; reception thresholds (SRT), speech discrimination scores, and acoustic

 ;; immittance with acoustic reflexes (ipsilateral and contralateral reflexes).

 ;; Tests for non-organicity must be performed when indicated.

 ;;

 ;; 1. Objective Findings:

 ;; a. Puretone thresholds in decibels (air conduction):

 ;;

 ;; Instructions: Measure and record puretone threshold values in decibels at the

 ;; indicated frequencies (air conduction).  Report the decibel value, which ranges

 ;; from -10 dB to 105 dB,  for each of the frequencies. Add a plus behind the

 ;; decibel value when a maximum value has been reached with a failure of response

 ;; from the Veteran. In those circumstances where the average includes a failure

 ;; of response at either the maximum allowable limit (105 dB) or the maximum

 ;; limits of the audiometer, use this maximum decibel value of the failure of 

 ;; response in the puretone threshold average calculation.

 ;;

 ;; If the Veteran could not be tested (CNT), enter CNT and state the reason why 

 ;; the Veteran could not be tested.  Clearly inaccurate, invalid or unreliable

 ;; test results should not be reported.

 ;;

 ;; The puretone threshold at 500 Hz is not used in calculating the puretone

 ;; threshold average for evaluation purposes but is used in determining whether

 ;; or not for VA purposes, hearing impairment reaches the level of a disability.

 ;; The puretone threshold average requires the decibel levels of each of the 

 ;; required frequencies (1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz) be recorded

 ;; for the test to be valid for determination of a hearing impairment.

 ;;

 ;;                                   RIGHT EAR

 ;;________________________________________________________________

 ;;|   A    |   B    |   C    |   D    |   E    |   F    |   G    |

 ;;|________|________|________|________|________|________|________|________________

 ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |

 ;;|________|________|________|________|________|________|________|_______________|

 ;;|        |        |        |        |        |        |        |               |

 ;;|________|________|________|________|________|________|________|_______________|

 ;;

 ;;                                   LEFT EAR

 ;;________________________________________________________________

 ;;|   A    |   B    |   C    |   D    |   E    |   F    |   G    |

 ;;|________|________|________|________|________|________|________|________________

 ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |

 ;;|________|________|________|________|________|________|________|_______________|

 ;;|        |        |        |        |        |        |        |               |

 ;;|________|________|________|________|________|________|________|_______________|

 ;; *The puretone threshold at 500 Hz is not used in determining the evaluation

 ;; but is used in determining whether or not a ratable hearing loss exists.

 ;; **The average of B, C, D, and E.

 ;; ***CNT - Could Not Test

 ;;

 ;; b. Were there one or more frequency(ies) that could not be tested?

 ;;    ___ Yes  ___ No

 ;; If yes, enter CNT in the box for frequency(ies) that could not be tested, and

 ;; explain why testing could not be done: ______________________________________

 ;;

 ;; c. Validity of puretone test results:

 ;;    ___ Test results are valid.

 ;;    ___ Test results are invalid (not indicative of organic hearing loss).

 ;;        If invalid, provide reason: __________________________________________

 ;;

 ;; d. Speech Discrimination Score (Maryland CNC word list)

 ;;    Instructions on pausing:  Examiners should pause when necessary during

 ;;    speech discrimination tests, in order to give the Veteran sufficient time

 ;;    to respond. This will ensure that the test results are based on actual

 ;;    hearing loss rather than on the effects of other problems that might slow

 ;;    a Veteran's response. There are a variety of problems that might require

 ;;    pausing, for example, the presence of cognitive impairment.  It is up to

 ;;    the examiner to determine when to use pausing and the length of the pauses.

 ;;

 ;;     RIGHT EAR  _________ %

 ;;

 ;;     LEFT EAR   _________ %

 ;;

 ;; e. Appropriateness of Use of Speech Discrimination Score (Maryland CNC word

 ;; list)

 ;;    ___ Use of speech discrimination score is appropriate for this Veteran.

 ;;    ___ The use of the speech discrimination score is not appropriate for

 ;;          this Veteran because of language difficulties, cognitive problems,

 ;;          inconsistent speech discrimination scores, etc., that make combined

 ;;          use of puretone average and speech discrimination scores

 ;;          inappropriate.

 ;;

 ;; f. Audiological Findings

 ;; Summary of Immittance (Tympanometry) Findings:

 ;;

 ;;                                RIGHT EAR                   LEFT EAR

 ;; Acoustic immittance      Normal___  Abnormal__       Normal___  Abnormal___

 ;; Ipsilateral Acoustic

 ;; Reflexes                 Normal___  Abnormal__       Normal___  Abnormal___

 ;; Contralateral Acoustic

 ;; Reflexes                 Normal___  Abnormal__       Normal___  Abnormal___

 ;; Unable to obtain/

 ;; maintain seal                  ______                         ______

 ;;^TOF^

 ;; 2. Diagnosis

 ;; RIGHT EAR

 ;;    ___ Normal hearing

 ;;    ___ Sensorineural hearing loss (in the frequency

 ;;        range of 500-4000 Hz)*                        ICD code: _____________

 ;;    ___ Sensorineural hearing loss (in the frequency

 ;;        range of 6000 Hz or higher frequencies) **    ICD code: _____________

 ;;    ___ Significant changes in hearing thresholds

 ;;        in service***                                 ICD code: _____________

 ;;    ___ Conductive hearing loss                       ICD code: _____________

 ;;    ___ Mixed hearing loss                            ICD code: _____________

 ;;

 ;; LEFT EAR

 ;;    ___ Normal hearing

 ;;    ___ Sensorineural hearing loss (in the frequency

 ;;        range of 500-4000 Hz)*                        ICD code: _____________

 ;;    ___ Sensorineural hearing loss(in the frequency

 ;;        range of 6000 Hz or higher frequencies) **    ICD code: _____________

 ;;    ___ Significant changes in hearing thresholds

 ;;        in service***                                 ICD code: _____________

 ;;    ___ Conductive hearing loss                       ICD code: _____________

 ;;    ___ Mixed hearing loss                            ICD code: _____________

 ;;

 ;; NOTES: 

 ;; * The Veteran may have hearing loss at a level that is not considered to be

 ;; a disability for VA purposes. This can occur when the auditory thresholds

 ;; are greater than 25 dB at one or more frequencies in the 500-4000 Hz range.

 ;;

 ;; ** The Veteran may have impaired hearing, but it does not meet the criteria

 ;; to be considered a disability for VA purposes. For VA proposes, the

 ;; diagnosis of hearing impairment is based upon testing at frequency ranges 

 ;; of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the 500-4000 Hz

 ;; range, but there is HL above 4000 Hz, check this box.

 ;;

 ;; *** The Veteran may have a significant change in hearing threshold in

 ;; service, but it does not meet the criteria to be considered a disability

 ;; for VA purposes. (A significant change in hearing threshold may indicate

 ;; noise exposure or acoustic trauma.)

 ;;  

 ;; 3. Evidence review

 ;; In order to provide an accurate medical opinion, the Veteran's records 

 ;; should be reviewed, if available.

 ;;

 ;; Was the Veteran's VA claims file reviewed?

 ;;    ___ Yes ___ No

 ;;

 ;; If yes, list any records that were reviewed but were not included in the

 ;; Veteran's VA claims file: ___________________________________________________

 ;;^TOF^ 

 ;; If no, check all records reviewed as part of this examination:

 ;;    ___ Military service treatment records

 ;;    ___ Military service personnel records

 ;;    ___ Military enlistment examination

 ;;    ___ Military separation examination

 ;;    ___ Military post-deployment questionnaire

 ;;    ___ Department of Defense Form 214 Separation Documents

 ;;    ___ Veterans Health Administration medical records (VA treatment records)

 ;;    ___ Civilian medical records

 ;;    ___ Interviews with collateral witnesses (family and others who have known

 ;;        the Veteran before and after military service)

 ;;    ___ Prior audiology reports

 ;;    ___ Other: ______________________________________

 ;;    ___ No records were reviewed

 ;;

 ;; 4. Etiology

 ;; If present, is the Veteran's hearing loss at least as likely as not (50% 

 ;; probability or greater) caused by or a result of an event in military service?

 ;;    ___ Yes

 ;;    ___ No

 ;;    Rationale (Provide rationale for either a yes or no answer): _____________

 ;;    __________________________________________________________________________

 ;;    ___ Cannot provide a medical opinion regarding the etiology of the Veteran's

 ;;        hearing loss without resorting to speculation

 ;;    Provide rationale for reason speculation required:  ______________________

 ;; Did hearing loss exist prior to the service?

 ;;    ___ Yes

 ;;    ___ No

 ;;    If yes, was the pre-existing hearing loss aggravated beyond normal

 ;;    progression in military service?

 ;;    Right ear   ___ Yes   ___ No

 ;;    Left ear    ___ Yes   ___ No

 ;; Provide rationale for both yes or no:  ______________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 5. Functional impact of hearing loss

 ;; NOTE: Ask the Veteran to describe in his or her own words the effects of

 ;; disability (i.e. the current complaint of hearing loss on occupational

 ;; functioning and daily activities). Document the Veteran's response without

 ;; opining on the relationship between the functional effects and the level

 ;; of impairment (audiogram) or otherwise characterizing the response. Do not

 ;; use handicap scales.

 ;;

 ;; Does the Veteran's hearing loss impact ordinary conditions of daily life,

 ;; including ability to work?

 ;;    ___ Yes    ___ No

 ;;    If yes, describe impact in the Veteran's own words: ______________________

 ;;    __________________________________________________________________________

 ;;  

 ;; 6. Remarks, if any, pertaining to hearing loss: _____________________________

 ;;    __________________________________________________________________________

 Q