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Routine: DVBCQHL5

DVBCQHL5.m

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  1. DVBCQHL5 ;ALB-CIOFO/SBW - HEARING LOSS QUESTIONNAIRE (V2) ; 30/JUN/2011
  1. ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
  1. ;
  1. TXT ;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1. ;; disability benefits. VA will consider the information you provide on this
  1. ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1. ;;
  1. ;; NOTE: This form is only for use by VHA staff or contract examiners.
  1. ;;
  1. ;; This exam is for:
  1. ;; ___ Tinnitus only (audiologist or non-audiologist clinician)
  1. ;; If this exam is for tinnitus only, complete section 2 only.
  1. ;; Otherwise complete entire form.
  1. ;; ___ Hearing loss and/or tinnitus (audiologist, performing current exam)
  1. ;; ___ Hearing loss and/or tinnitus (audiologist or non-audiologist clinician,
  1. ;; using audiology report of record that represents Veteran's current
  1. ;; condition)
  1. ;; If using audiology report of record, date audiology exam was
  1. ;; performed: ______________
  1. ;;
  1. ;; SECTION 1: HEARING LOSS (HL)
  1. ;;
  1. ;; Note: All testing must be conducted in accordance with the following
  1. ;; instructions to be valid for VA disability evaluation purposes.
  1. ;;
  1. ;; Instructions: An examination of hearing impairment must be conducted by a
  1. ;; state-licensed audiologist and must include a controlled speech discrimination
  1. ;; test (specifically, the Maryland CNC recording) and a puretone audiometry
  1. ;; test in a sound isolated booth that meets American National Standards
  1. ;; Institute standards (ANSI S3.1.1999 [R2004]) for ambient noise. Measurements
  1. ;; will be reported at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz.
  1. ;;
  1. ;; The examination will include the following tests: Puretone audiometry by
  1. ;; air conduction at 250, 500, 1000, 2000, 3000, 4000, 6000 Hz and 8000 Hz,
  1. ;; and by bone conduction at 250, 500, 1000, 2000, 3000, and 4000 Hz, spondee
  1. ;; thresholds, speech discrimination using the recorded Maryland CNC Test,
  1. ;; tympanometry and acoustic reflex tests (ipsilateral and contralateral), and,
  1. ;; when necessary, Stenger tests. Bone conduction thresholds are measured when
  1. ;; the air conduction thresholds are poorer than 15 dB HL. A modified Hughson-
  1. ;; Westlake procedure will be used with appropriate masking. A Stenger must
  1. ;; be administered whenever puretone air conduction thresholds at 500, 1000,
  1. ;; 2000, 3000, and 4000 Hz differ by 20 dB or more between the two ears.
  1. ;;
  1. ;; Maximum speech discrimination will be reported with the 50 word VA approved
  1. ;; recording of the Maryland CNC test. The starting presentation level will be
  1. ;; 40 dB re SRT. If necessary, the starting level will be adjusted upward to
  1. ;; obtain a level at least 5 dB above the threshold at 2000 Hz, if not above
  1. ;; the patient's tolerance level.
  1. ;;
  1. ;; The examination will be conducted without the use of hearing aids. Both
  1. ;; ears must be examined for hearing impairment even if hearing loss in only
  1. ;; one ear is at issue.
  1. ;;^TOF^
  1. ;; When speech discrimination is 92% or less, a performance intensity function
  1. ;; must be obtained.
  1. ;;
  1. ;; A comprehensive audiological evaluation should include evaluation results
  1. ;; for puretone thresholds by air and bone conduction (500-8000 Hz), speech
  1. ;; reception thresholds (SRT), speech discrimination scores, and acoustic
  1. ;; immittance with acoustic reflexes (ipsilateral and contralateral reflexes).
  1. ;; Tests for non-organicity must be performed when indicated.
  1. ;;
  1. ;; 1. Objective Findings:
  1. ;; a. Puretone thresholds in decibels (air conduction):
  1. ;;
  1. ;; Instructions: Measure and record puretone threshold values in decibels at the
  1. ;; indicated frequencies (air conduction). Report the decibel (dB) value, which
  1. ;; ranges from -10 dB to 105 dB, for each of the frequencies. Add a plus behind
  1. ;; the decibel value when a maximum value has been reached with a failure of
  1. ;; response from the Veteran. In those circumstances where the average includes
  1. ;; a failure of response at either the maximum allowable limit (105 dB) or the
  1. ;; maximum limits of the audiometer, use this maximum decibel value of the
  1. ;; failure of response in the puretone threshold average calculation.
  1. ;;
  1. ;; If the Veteran could not be tested (CNT), enter CNT and state the reason why
  1. ;; the Veteran could not be tested. Clearly inaccurate, invalid or unreliable
  1. ;; test results should not be reported.
  1. ;;
  1. ;; The puretone threshold at 500 Hz is not used in calculating the puretone
  1. ;; threshold average for evaluation purposes but is used in determining whether
  1. ;; or not for VA purposes, hearing impairment reaches the level of a disability.
  1. ;; The puretone threshold average requires the decibel levels of each of the
  1. ;; required frequencies (1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz) be recorded
  1. ;; for the test to be valid for determination of a hearing impairment.
  1. ;;
  1. ;; RIGHT EAR
  1. ;;________________________________________________________________
  1. ;;| A | B | C | D | E | F | G |
  1. ;;|________|________|________|________|________|________|________|________________
  1. ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |
  1. ;;|________|________|________|________|________|________|________|_______________|
  1. ;;| | | | | | | | |
  1. ;;|________|________|________|________|________|________|________|_______________|
  1. ;;
  1. ;;^TOF^
  1. ;; LEFT EAR
  1. ;;________________________________________________________________
  1. ;;| A | B | C | D | E | F | G |
  1. ;;|________|________|________|________|________|________|________|________________
  1. ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |
  1. ;;|________|________|________|________|________|________|________|_______________|
  1. ;;| | | | | | | | |
  1. ;;|________|________|________|________|________|________|________|_______________|
  1. ;; *The puretone threshold at 500 Hz is not used in determining the evaluation
  1. ;; but is used in determining whether or not a ratable hearing loss exists.
  1. ;; **The average of B, C, D, and E.
  1. ;; ***CNT - Could Not Test
  1. ;;
  1. ;; b. Were there one or more frequency(ies) that could not be tested?
  1. ;; ___ Yes ___ No
  1. ;; If yes, enter CNT in the box for frequency(ies) that could not be tested, and
  1. ;; explain why testing could not be done: ______________________________________
  1. ;;
  1. ;; c. Validity of puretone test results:
  1. ;; ___ Test results are valid for rating purposes.
  1. ;; ___ Test results are not valid for rating purposes (not indicative of
  1. ;; organic hearing loss).
  1. ;; If invalid, provide reason: __________________________________________
  1. ;;
  1. ;; d. Speech Discrimination Score (Maryland CNC word list)
  1. ;; Instructions on pausing: Examiners should pause when necessary during
  1. ;; speech discrimination tests, in order to give the Veteran sufficient time
  1. ;; to respond. This will ensure that the test results are based on actual
  1. ;; hearing loss rather than on the effects of other problems that might slow
  1. ;; a Veteran's response. There are a variety of problems that might require
  1. ;; pausing, for example, the presence of cognitive impairment. It is up to
  1. ;; the examiner to determine when to use pausing and the length of the pauses.
  1. ;;
  1. ;; RIGHT EAR _________ %
  1. ;;
  1. ;; LEFT EAR _________ %
  1. ;;
  1. ;; e. Appropriateness of Use of Speech Discrimination Score (Maryland CNC word
  1. ;; list)
  1. ;; ___ Use of speech discrimination score is appropriate for this Veteran.
  1. ;; ___ The use of the speech discrimination score is not appropriate for
  1. ;; this Veteran because of language difficulties, cognitive problems,
  1. ;; inconsistent speech discrimination scores, etc., that make combined
  1. ;; use of puretone average and speech discrimination scores
  1. ;; inappropriate.
  1. ;;^TOF^
  1. ;; f. Audiologic Findings
  1. ;; Summary of Immittance (Tympanometry) Findings:
  1. ;;
  1. ;; RIGHT EAR LEFT EAR
  1. ;; Acoustic immittance Normal___ Abnormal__ Normal___ Abnormal___
  1. ;; Ipsilateral Acoustic
  1. ;; Reflexes Normal___ Abnormal__ Normal___ Abnormal___
  1. ;; Contralateral Acoustic
  1. ;; Reflexes Normal___ Abnormal__ Normal___ Abnormal___
  1. ;; Unable to interpret reflexes
  1. ;; due to artifact ______ ______
  1. ;; Unable to obtain/
  1. ;; maintain seal ______ ______
  1. ;;
  1. ;; 2. Diagnosis
  1. ;; RIGHT EAR
  1. ;; ___ Normal hearing
  1. ;; ___ Conductive hearing loss ICD code: ______
  1. ;; ___ Mixed hearing loss ICD code: ______
  1. ;; ___ Sensorineural hearing loss (in the frequency
  1. ;; range of 500-4000 Hz)* ICD code: _____________
  1. ;; ___ Sensorineural hearing loss (in the frequency
  1. ;; range of 6000 Hz or higher frequencies) ** ICD code: _____________
  1. ;; ___ Significant changes in hearing thresholds in service***
  1. ;;
  1. ;; LEFT EAR
  1. ;; ___ Normal hearing
  1. ;; ___ Conductive hearing loss ICD code: _____________
  1. ;; ___ Mixed hearing loss ICD code: _____________
  1. ;; ___ Sensorineural hearing loss (in the frequency
  1. ;; range of 500-4000 Hz)* ICD code: _____________
  1. ;; ___ Sensorineural hearing loss(in the frequency
  1. ;; range of 6000 Hz or higher frequencies) ** ICD code: _____________
  1. ;; ___ Significant changes in hearing thresholds in service***
  1. ;;
  1. ;; NOTES:
  1. ;; * The Veteran may have hearing loss at a level that is not considered to be
  1. ;; a disability for VA purposes. This can occur when the auditory thresholds
  1. ;; are greater than 25 dB at one or more frequencies in the 500-4000 Hz range.
  1. ;;
  1. ;; ** The Veteran may have impaired hearing, but it does not meet the criteria
  1. ;; to be considered a disability for VA purposes. For VA purposes, the
  1. ;; diagnosis of hearing impairment is based upon testing at frequency ranges
  1. ;; of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the 500-4000 Hz
  1. ;; range, but there is HL above 4000 Hz, check this box.
  1. ;;
  1. ;; *** The Veteran may have a significant change in hearing threshold in
  1. ;; service, but it does not meet the criteria to be considered a disability
  1. ;; for VA purposes. (A significant change in hearing threshold may indicate
  1. ;; noise exposure or acoustic trauma.)
  1. ;;^TOF^
  1. ;; 3. Evidence review
  1. ;; In order to provide an accurate medical opinion, the Veteran's records
  1. ;; should be reviewed, if available.
  1. ;;
  1. ;; Was the Veteran's VA claims file reviewed?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, list any records that were reviewed but were not included in the
  1. ;; Veteran's VA claims file: ___________________________________________________
  1. ;;
  1. ;; If no, check all records reviewed as part of this examination:
  1. ;; ___ Military service treatment records
  1. ;; ___ Military service personnel records
  1. ;; ___ Military enlistment examination
  1. ;; ___ Military separation examination
  1. ;; ___ Military post-deployment questionnaire
  1. ;; ___ Department of Defense Form 214 Separation Documents
  1. ;; ___ Veterans Health Administration medical records (VA treatment records)
  1. ;; ___ Civilian medical records
  1. ;; ___ Interviews with collateral witnesses (family and others who have known
  1. ;; the Veteran before and after military service)
  1. ;; ___ Prior audiology reports
  1. ;; ___ Other: ______________________________________
  1. ;; ___ No records were reviewed
  1. ;;
  1. ;; 4. Etiology
  1. ;; If present, is the Veteran's hearing loss at least as likely as not (50%
  1. ;; probability or greater) caused by or a result of an event in military service?
  1. ;; ___ Yes
  1. ;; ___ No
  1. ;; Rationale (Provide rationale for either a yes or no answer): _____________
  1. ;; __________________________________________________________________________
  1. ;; ___ Cannot provide a medical opinion regarding the etiology of the Veteran's
  1. ;; hearing loss without resorting to speculation
  1. ;; Provide rationale for reason speculation required: ______________________
  1. ;; Did hearing loss exist prior to the service?
  1. ;; ___ Yes
  1. ;; ___ No
  1. ;; If yes, was the pre-existing hearing loss aggravated beyond normal
  1. ;; progression in military service?
  1. ;; Right ear ___ Yes ___ No
  1. ;; Left ear ___ Yes ___ No
  1. ;; Provide rationale for both yes or no: ______________________________________
  1. ;; _____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 5. Functional impact of hearing loss
  1. ;; NOTE: Ask the Veteran to describe in his or her own words the effects of
  1. ;; disability (i.e. the current complaint of hearing loss on occupational
  1. ;; functioning and daily activities). Document the Veteran's response without
  1. ;; opining on the relationship between the functional effects and the level
  1. ;; of impairment (audiogram) or otherwise characterizing the response. Do not
  1. ;; use handicap scales.
  1. ;;
  1. ;; Does the Veteran's hearing loss impact ordinary conditions of daily life,
  1. ;; including ability to work?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe impact in the Veteran's own words: ______________________
  1. ;; __________________________________________________________________________
  1. ;;
  1. ;; 6. Remarks, if any, pertaining to hearing loss: _____________________________
  1. ;; __________________________________________________________________________
  1. Q