- DVBCQHL5 ;ALB-CIOFO/SBW - HEARING LOSS QUESTIONNAIRE (V2) ; 30/JUN/2011
- ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
- ;
- 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.
- ;;^TOF^
- ;; 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 (dB) 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)** |
- ;;|________|________|________|________|________|________|________|_______________|
- ;;| | | | | | | | |
- ;;|________|________|________|________|________|________|________|_______________|
- ;;
- ;;^TOF^
- ;; 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 for rating purposes.
- ;; ___ Test results are not valid for rating purposes (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.
- ;;^TOF^
- ;; f. Audiologic 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 interpret reflexes
- ;; due to artifact ______ ______
- ;; Unable to obtain/
- ;; maintain seal ______ ______
- ;;
- ;; 2. Diagnosis
- ;; RIGHT EAR
- ;; ___ Normal hearing
- ;; ___ Conductive hearing loss ICD code: ______
- ;; ___ Mixed hearing loss ICD code: ______
- ;; ___ 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***
- ;;
- ;; LEFT EAR
- ;; ___ Normal hearing
- ;; ___ Conductive hearing loss ICD code: _____________
- ;; ___ Mixed hearing loss ICD code: _____________
- ;; ___ 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***
- ;;
- ;; 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 purposes, 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.)
- ;;^TOF^
- ;; 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: ___________________________________________________
- ;;
- ;; 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: ______________________________________
- ;; _____________________________________________________________________________
- ;;^TOF^
- ;; 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
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHL5 14134 printed Feb 18, 2025@23:13:06 Page 2
- DVBCQHL5 ;ALB-CIOFO/SBW - HEARING LOSS QUESTIONNAIRE (V2) ; 30/JUN/2011
- +1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
- +2 ;
- TXT ;
- +1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
- +2 ;; disability benefits. VA will consider the information you provide on this
- +3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
- +4 ;;
- +5 ;; NOTE: This form is only for use by VHA staff or contract examiners.
- +6 ;;
- +7 ;; This exam is for:
- +8 ;; ___ Tinnitus only (audiologist or non-audiologist clinician)
- +9 ;; If this exam is for tinnitus only, complete section 2 only.
- +10 ;; Otherwise complete entire form.
- +11 ;; ___ Hearing loss and/or tinnitus (audiologist, performing current exam)
- +12 ;; ___ Hearing loss and/or tinnitus (audiologist or non-audiologist clinician,
- +13 ;; using audiology report of record that represents Veteran's current
- +14 ;; condition)
- +15 ;; If using audiology report of record, date audiology exam was
- +16 ;; performed: ______________
- +17 ;;
- +18 ;; SECTION 1: HEARING LOSS (HL)
- +19 ;;
- +20 ;; Note: All testing must be conducted in accordance with the following
- +21 ;; instructions to be valid for VA disability evaluation purposes.
- +22 ;;
- +23 ;; Instructions: An examination of hearing impairment must be conducted by a
- +24 ;; state-licensed audiologist and must include a controlled speech discrimination
- +25 ;; test (specifically, the Maryland CNC recording) and a puretone audiometry
- +26 ;; test in a sound isolated booth that meets American National Standards
- +27 ;; Institute standards (ANSI S3.1.1999 [R2004]) for ambient noise. Measurements
- +28 ;; will be reported at the frequencies of 500, 1000, 2000, 3000, and 4000 Hz.
- +29 ;;
- +30 ;; The examination will include the following tests: Puretone audiometry by
- +31 ;; air conduction at 250, 500, 1000, 2000, 3000, 4000, 6000 Hz and 8000 Hz,
- +32 ;; and by bone conduction at 250, 500, 1000, 2000, 3000, and 4000 Hz, spondee
- +33 ;; thresholds, speech discrimination using the recorded Maryland CNC Test,
- +34 ;; tympanometry and acoustic reflex tests (ipsilateral and contralateral), and,
- +35 ;; when necessary, Stenger tests. Bone conduction thresholds are measured when
- +36 ;; the air conduction thresholds are poorer than 15 dB HL. A modified Hughson-
- +37 ;; Westlake procedure will be used with appropriate masking. A Stenger must
- +38 ;; be administered whenever puretone air conduction thresholds at 500, 1000,
- +39 ;; 2000, 3000, and 4000 Hz differ by 20 dB or more between the two ears.
- +40 ;;
- +41 ;; Maximum speech discrimination will be reported with the 50 word VA approved
- +42 ;; recording of the Maryland CNC test. The starting presentation level will be
- +43 ;; 40 dB re SRT. If necessary, the starting level will be adjusted upward to
- +44 ;; obtain a level at least 5 dB above the threshold at 2000 Hz, if not above
- +45 ;; the patient's tolerance level.
- +46 ;;
- +47 ;; The examination will be conducted without the use of hearing aids. Both
- +48 ;; ears must be examined for hearing impairment even if hearing loss in only
- +49 ;; one ear is at issue.
- +50 ;;^TOF^
- +51 ;; When speech discrimination is 92% or less, a performance intensity function
- +52 ;; must be obtained.
- +53 ;;
- +54 ;; A comprehensive audiological evaluation should include evaluation results
- +55 ;; for puretone thresholds by air and bone conduction (500-8000 Hz), speech
- +56 ;; reception thresholds (SRT), speech discrimination scores, and acoustic
- +57 ;; immittance with acoustic reflexes (ipsilateral and contralateral reflexes).
- +58 ;; Tests for non-organicity must be performed when indicated.
- +59 ;;
- +60 ;; 1. Objective Findings:
- +61 ;; a. Puretone thresholds in decibels (air conduction):
- +62 ;;
- +63 ;; Instructions: Measure and record puretone threshold values in decibels at the
- +64 ;; indicated frequencies (air conduction). Report the decibel (dB) value, which
- +65 ;; ranges from -10 dB to 105 dB, for each of the frequencies. Add a plus behind
- +66 ;; the decibel value when a maximum value has been reached with a failure of
- +67 ;; response from the Veteran. In those circumstances where the average includes
- +68 ;; a failure of response at either the maximum allowable limit (105 dB) or the
- +69 ;; maximum limits of the audiometer, use this maximum decibel value of the
- +70 ;; failure of response in the puretone threshold average calculation.
- +71 ;;
- +72 ;; If the Veteran could not be tested (CNT), enter CNT and state the reason why
- +73 ;; the Veteran could not be tested. Clearly inaccurate, invalid or unreliable
- +74 ;; test results should not be reported.
- +75 ;;
- +76 ;; The puretone threshold at 500 Hz is not used in calculating the puretone
- +77 ;; threshold average for evaluation purposes but is used in determining whether
- +78 ;; or not for VA purposes, hearing impairment reaches the level of a disability.
- +79 ;; The puretone threshold average requires the decibel levels of each of the
- +80 ;; required frequencies (1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz) be recorded
- +81 ;; for the test to be valid for determination of a hearing impairment.
- +82 ;;
- +83 ;; RIGHT EAR
- +84 ;;________________________________________________________________
- +85 ;;| A | B | C | D | E | F | G |
- +86 ;;|________|________|________|________|________|________|________|________________
- +87 ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |
- +88 ;;|________|________|________|________|________|________|________|_______________|
- +89 ;;| | | | | | | | |
- +90 ;;|________|________|________|________|________|________|________|_______________|
- +91 ;;
- +92 ;;^TOF^
- +93 ;; LEFT EAR
- +94 ;;________________________________________________________________
- +95 ;;| A | B | C | D | E | F | G |
- +96 ;;|________|________|________|________|________|________|________|________________
- +97 ;;| 500Hz* | 1000Hz | 2000Hz | 3000Hz | 4000Hz | 6000Hz | 8000Hz |Avg Hz (B-E)** |
- +98 ;;|________|________|________|________|________|________|________|_______________|
- +99 ;;| | | | | | | | |
- +100 ;;|________|________|________|________|________|________|________|_______________|
- +101 ;; *The puretone threshold at 500 Hz is not used in determining the evaluation
- +102 ;; but is used in determining whether or not a ratable hearing loss exists.
- +103 ;; **The average of B, C, D, and E.
- +104 ;; ***CNT - Could Not Test
- +105 ;;
- +106 ;; b. Were there one or more frequency(ies) that could not be tested?
- +107 ;; ___ Yes ___ No
- +108 ;; If yes, enter CNT in the box for frequency(ies) that could not be tested, and
- +109 ;; explain why testing could not be done: ______________________________________
- +110 ;;
- +111 ;; c. Validity of puretone test results:
- +112 ;; ___ Test results are valid for rating purposes.
- +113 ;; ___ Test results are not valid for rating purposes (not indicative of
- +114 ;; organic hearing loss).
- +115 ;; If invalid, provide reason: __________________________________________
- +116 ;;
- +117 ;; d. Speech Discrimination Score (Maryland CNC word list)
- +118 ;; Instructions on pausing: Examiners should pause when necessary during
- +119 ;; speech discrimination tests, in order to give the Veteran sufficient time
- +120 ;; to respond. This will ensure that the test results are based on actual
- +121 ;; hearing loss rather than on the effects of other problems that might slow
- +122 ;; a Veteran's response. There are a variety of problems that might require
- +123 ;; pausing, for example, the presence of cognitive impairment. It is up to
- +124 ;; the examiner to determine when to use pausing and the length of the pauses.
- +125 ;;
- +126 ;; RIGHT EAR _________ %
- +127 ;;
- +128 ;; LEFT EAR _________ %
- +129 ;;
- +130 ;; e. Appropriateness of Use of Speech Discrimination Score (Maryland CNC word
- +131 ;; list)
- +132 ;; ___ Use of speech discrimination score is appropriate for this Veteran.
- +133 ;; ___ The use of the speech discrimination score is not appropriate for
- +134 ;; this Veteran because of language difficulties, cognitive problems,
- +135 ;; inconsistent speech discrimination scores, etc., that make combined
- +136 ;; use of puretone average and speech discrimination scores
- +137 ;; inappropriate.
- +138 ;;^TOF^
- +139 ;; f. Audiologic Findings
- +140 ;; Summary of Immittance (Tympanometry) Findings:
- +141 ;;
- +142 ;; RIGHT EAR LEFT EAR
- +143 ;; Acoustic immittance Normal___ Abnormal__ Normal___ Abnormal___
- +144 ;; Ipsilateral Acoustic
- +145 ;; Reflexes Normal___ Abnormal__ Normal___ Abnormal___
- +146 ;; Contralateral Acoustic
- +147 ;; Reflexes Normal___ Abnormal__ Normal___ Abnormal___
- +148 ;; Unable to interpret reflexes
- +149 ;; due to artifact ______ ______
- +150 ;; Unable to obtain/
- +151 ;; maintain seal ______ ______
- +152 ;;
- +153 ;; 2. Diagnosis
- +154 ;; RIGHT EAR
- +155 ;; ___ Normal hearing
- +156 ;; ___ Conductive hearing loss ICD code: ______
- +157 ;; ___ Mixed hearing loss ICD code: ______
- +158 ;; ___ Sensorineural hearing loss (in the frequency
- +159 ;; range of 500-4000 Hz)* ICD code: _____________
- +160 ;; ___ Sensorineural hearing loss (in the frequency
- +161 ;; range of 6000 Hz or higher frequencies) ** ICD code: _____________
- +162 ;; ___ Significant changes in hearing thresholds in service***
- +163 ;;
- +164 ;; LEFT EAR
- +165 ;; ___ Normal hearing
- +166 ;; ___ Conductive hearing loss ICD code: _____________
- +167 ;; ___ Mixed hearing loss ICD code: _____________
- +168 ;; ___ Sensorineural hearing loss (in the frequency
- +169 ;; range of 500-4000 Hz)* ICD code: _____________
- +170 ;; ___ Sensorineural hearing loss(in the frequency
- +171 ;; range of 6000 Hz or higher frequencies) ** ICD code: _____________
- +172 ;; ___ Significant changes in hearing thresholds in service***
- +173 ;;
- +174 ;; NOTES:
- +175 ;; * The Veteran may have hearing loss at a level that is not considered to be
- +176 ;; a disability for VA purposes. This can occur when the auditory thresholds
- +177 ;; are greater than 25 dB at one or more frequencies in the 500-4000 Hz range.
- +178 ;;
- +179 ;; ** The Veteran may have impaired hearing, but it does not meet the criteria
- +180 ;; to be considered a disability for VA purposes. For VA purposes, the
- +181 ;; diagnosis of hearing impairment is based upon testing at frequency ranges
- +182 ;; of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the 500-4000 Hz
- +183 ;; range, but there is HL above 4000 Hz, check this box.
- +184 ;;
- +185 ;; *** The Veteran may have a significant change in hearing threshold in
- +186 ;; service, but it does not meet the criteria to be considered a disability
- +187 ;; for VA purposes. (A significant change in hearing threshold may indicate
- +188 ;; noise exposure or acoustic trauma.)
- +189 ;;^TOF^
- +190 ;; 3. Evidence review
- +191 ;; In order to provide an accurate medical opinion, the Veteran's records
- +192 ;; should be reviewed, if available.
- +193 ;;
- +194 ;; Was the Veteran's VA claims file reviewed?
- +195 ;; ___ Yes ___ No
- +196 ;;
- +197 ;; If yes, list any records that were reviewed but were not included in the
- +198 ;; Veteran's VA claims file: ___________________________________________________
- +199 ;;
- +200 ;; If no, check all records reviewed as part of this examination:
- +201 ;; ___ Military service treatment records
- +202 ;; ___ Military service personnel records
- +203 ;; ___ Military enlistment examination
- +204 ;; ___ Military separation examination
- +205 ;; ___ Military post-deployment questionnaire
- +206 ;; ___ Department of Defense Form 214 Separation Documents
- +207 ;; ___ Veterans Health Administration medical records (VA treatment records)
- +208 ;; ___ Civilian medical records
- +209 ;; ___ Interviews with collateral witnesses (family and others who have known
- +210 ;; the Veteran before and after military service)
- +211 ;; ___ Prior audiology reports
- +212 ;; ___ Other: ______________________________________
- +213 ;; ___ No records were reviewed
- +214 ;;
- +215 ;; 4. Etiology
- +216 ;; If present, is the Veteran's hearing loss at least as likely as not (50%
- +217 ;; probability or greater) caused by or a result of an event in military service?
- +218 ;; ___ Yes
- +219 ;; ___ No
- +220 ;; Rationale (Provide rationale for either a yes or no answer): _____________
- +221 ;; __________________________________________________________________________
- +222 ;; ___ Cannot provide a medical opinion regarding the etiology of the Veteran's
- +223 ;; hearing loss without resorting to speculation
- +224 ;; Provide rationale for reason speculation required: ______________________
- +225 ;; Did hearing loss exist prior to the service?
- +226 ;; ___ Yes
- +227 ;; ___ No
- +228 ;; If yes, was the pre-existing hearing loss aggravated beyond normal
- +229 ;; progression in military service?
- +230 ;; Right ear ___ Yes ___ No
- +231 ;; Left ear ___ Yes ___ No
- +232 ;; Provide rationale for both yes or no: ______________________________________
- +233 ;; _____________________________________________________________________________
- +234 ;;^TOF^
- +235 ;; 5. Functional impact of hearing loss
- +236 ;; NOTE: Ask the Veteran to describe in his or her own words the effects of
- +237 ;; disability (i.e. the current complaint of hearing loss on occupational
- +238 ;; functioning and daily activities). Document the Veteran's response without
- +239 ;; opining on the relationship between the functional effects and the level
- +240 ;; of impairment (audiogram) or otherwise characterizing the response. Do not
- +241 ;; use handicap scales.
- +242 ;;
- +243 ;; Does the Veteran's hearing loss impact ordinary conditions of daily life,
- +244 ;; including ability to work?
- +245 ;; ___ Yes ___ No
- +246 ;; If yes, describe impact in the Veteran's own words: ______________________
- +247 ;; __________________________________________________________________________
- +248 ;;
- +249 ;; 6. Remarks, if any, pertaining to hearing loss: _____________________________
- +250 ;; __________________________________________________________________________
- +251 QUIT