DVBCQHL3 ;ALB-CIOFO/ECF,SBW - HEARING LOSS QUESTIONNAIRE (continued) ; 18/May/2011
;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
;
TXT ;
;;^TOF^
;; SECTION 2: TINNITUS
;; 1. Medical history
;; Does the Veteran report recurrent tinnitus?
;; ___ Yes ___ No
;;
;; Date and circumstances of onset of tinnitus: ________________________________
;;
;; 2. 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: _______________________________________________
;;
;; 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
;;
;; 3. Etiology of tinnitus
;; a. Tinnitus associated with hearing loss
;; ___ The Veteran has a diagnosis of hearing loss according to VA
;; criteria, and his or her tinnitus is at least as likely as not (50%
;; probability or greater) a symptom associated with the hearing loss,
;; as tinnitus is known to be a symptom associated with hearing loss
;; ___ The Veteran's tinnitus is not likely a symptom associated with
;; Veteran's hearing loss, as Veteran does not have hearing loss
;; according to VA criteria
;;^TOF^
;; b. Tinnitus not associated with hearing loss
;; NOTE: Select answer below and provide rationale.
;;
;; The Veteran's tinnitus is:
;; ___ At least as likely as not (50% probability or greater) caused by or a
;; result of military noise exposure
;; Rationale: ________________________________________________________
;; ___ At least as likely as not (50% probability or greater) due to a known
;; etiology (such as traumatic brain injury)
;; Etiology and rationale: ___________________________________________
;; ___ Not caused by or a result of military noise exposure
;; Rationale: ________________________________________________________
;; ___ Cannot provide a medical opinion regarding the etiology of the
;; Veteran's tinnitus without resorting to speculation
;; Reason speculation required: _____________________________________
;;
;; 4. Functional impact of tinnitus
;; NOTE: Ask the Veteran to describe in his or her own words the effects of
;; disability (i.e. the current complaint of tinnitus 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 tinnitus impact ordinary conditions of daily life,
;; including ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe impact in the Veteran's own words: ______________________
;;
;; 5. Remarks, if any, pertaining to tinnitus: _________________________________
;; _____________________________________________________________________________
;;
;; Audiologist/clinician signature: _______________________ Date: ______________
;;
;; Audiologist/clinician printed name: _________________________________________
;;
;; State audiology/examiner license #: _________________________________________
;;
;; Physician address: __________________________________________________________
;;
;; Phone: ________________________________ Fax: _______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's application.
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHL3 4544 printed Apr 09, 2024@20:54:17 Page 2
DVBCQHL3 ;ALB-CIOFO/ECF,SBW - HEARING LOSS QUESTIONNAIRE (continued) ; 18/May/2011
+1 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
+2 ;
TXT ;
+1 ;;^TOF^
+2 ;; SECTION 2: TINNITUS
+3 ;; 1. Medical history
+4 ;; Does the Veteran report recurrent tinnitus?
+5 ;; ___ Yes ___ No
+6 ;;
+7 ;; Date and circumstances of onset of tinnitus: ________________________________
+8 ;;
+9 ;; 2. Evidence review
+10 ;; In order to provide an accurate medical opinion, the Veteran's records
+11 ;; should be reviewed, if available.
+12 ;;
+13 ;; Was the Veteran's VA claims file reviewed?
+14 ;; ___ Yes ___ No
+15 ;;
+16 ;; If yes, list any records that were reviewed but were not included in
+17 ;; the Veteran's VA claims file: _______________________________________________
+18 ;;
+19 ;; If no, check all records reviewed as part of this examination:
+20 ;; ___ Military service treatment records
+21 ;; ___ Military service personnel records
+22 ;; ___ Military enlistment examination
+23 ;; ___ Military separation examination
+24 ;; ___ Military post-deployment questionnaire
+25 ;; ___ Department of Defense Form 214 Separation Documents
+26 ;; ___ Veterans Health Administration medical records (VA treatment records)
+27 ;; ___ Civilian medical records
+28 ;; ___ Interviews with collateral witnesses (family and others who have
+29 ;; known the Veteran before and after military service)
+30 ;; ___ Prior audiology reports
+31 ;; ___ Other: ______________________________________
+32 ;; ___ No records were reviewed
+33 ;;
+34 ;; 3. Etiology of tinnitus
+35 ;; a. Tinnitus associated with hearing loss
+36 ;; ___ The Veteran has a diagnosis of hearing loss according to VA
+37 ;; criteria, and his or her tinnitus is at least as likely as not (50%
+38 ;; probability or greater) a symptom associated with the hearing loss,
+39 ;; as tinnitus is known to be a symptom associated with hearing loss
+40 ;; ___ The Veteran's tinnitus is not likely a symptom associated with
+41 ;; Veteran's hearing loss, as Veteran does not have hearing loss
+42 ;; according to VA criteria
+43 ;;^TOF^
+44 ;; b. Tinnitus not associated with hearing loss
+45 ;; NOTE: Select answer below and provide rationale.
+46 ;;
+47 ;; The Veteran's tinnitus is:
+48 ;; ___ At least as likely as not (50% probability or greater) caused by or a
+49 ;; result of military noise exposure
+50 ;; Rationale: ________________________________________________________
+51 ;; ___ At least as likely as not (50% probability or greater) due to a known
+52 ;; etiology (such as traumatic brain injury)
+53 ;; Etiology and rationale: ___________________________________________
+54 ;; ___ Not caused by or a result of military noise exposure
+55 ;; Rationale: ________________________________________________________
+56 ;; ___ Cannot provide a medical opinion regarding the etiology of the
+57 ;; Veteran's tinnitus without resorting to speculation
+58 ;; Reason speculation required: _____________________________________
+59 ;;
+60 ;; 4. Functional impact of tinnitus
+61 ;; NOTE: Ask the Veteran to describe in his or her own words the effects of
+62 ;; disability (i.e. the current complaint of tinnitus on occupational
+63 ;; functioning and daily activities). Document the Veteran's response without
+64 ;; opining on the relationship between the functional effects and the level of
+65 ;; impairment (audiogram) or otherwise characterizing the response. Do not use
+66 ;; handicap scales.
+67 ;;
+68 ;; Does the Veteran's tinnitus impact ordinary conditions of daily life,
+69 ;; including ability to work?
+70 ;; ___ Yes ___ No
+71 ;;
+72 ;; If yes, describe impact in the Veteran's own words: ______________________
+73 ;;
+74 ;; 5. Remarks, if any, pertaining to tinnitus: _________________________________
+75 ;; _____________________________________________________________________________
+76 ;;
+77 ;; Audiologist/clinician signature: _______________________ Date: ______________
+78 ;;
+79 ;; Audiologist/clinician printed name: _________________________________________
+80 ;;
+81 ;; State audiology/examiner license #: _________________________________________
+82 ;;
+83 ;; Physician address: __________________________________________________________
+84 ;;
+85 ;; Phone: ________________________________ Fax: _______________________________
+86 ;;
+87 ;; NOTE: VA may request additional medical information, including additional
+88 ;; examinations if necessary to complete VA's review of the Veteran's application.
+89 ;;^END^
+90 QUIT
