DVBCQHL6 ;ALB-CIOFO/SBW - HEARING LOSS QUESTIONNAIRE (V2 continued) ; 30/JUN/2011
;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
;
TXT ;
;;
;; 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
;;^TOF^
;; 3. Etiology of tinnitus
;; Select answer below and provide rationale where requested:
;; ___ The Veteran has a diagnosis of clinical hearing loss, 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
;; ___ Less likely than not (less than 50% probability) a symptom associated
;; with the Veterans hearing loss
;; Rationale: ________________________________________________________
;; ___ 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: ___________________________________________
;; ___ Less likely than not (less than 50% probability) 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[HDVBCQHL6 4463 printed Dec 13, 2024@01:46:41 Page 2
DVBCQHL6 ;ALB-CIOFO/SBW - HEARING LOSS QUESTIONNAIRE (V2 continued) ; 30/JUN/2011
+1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;;
+2 ;; SECTION 2: TINNITUS
+3 ;; 1. Medical history
+4 ;; Does the Veteran report recurrent tinnitus?
+5 ;; ___ Yes ___ No
+6 ;; Date and circumstances of onset of tinnitus: ________________________________
+7 ;;
+8 ;; 2. Evidence review
+9 ;; In order to provide an accurate medical opinion, the Veteran's records
+10 ;; should be reviewed, if available.
+11 ;;
+12 ;; Was the Veteran's VA claims file reviewed?
+13 ;; ___ Yes ___ No
+14 ;; If yes, list any records that were reviewed but were not included in
+15 ;; the Veteran's VA claims file: _______________________________________________
+16 ;;
+17 ;; If no, check all records reviewed as part of this examination:
+18 ;; ___ Military service treatment records
+19 ;; ___ Military service personnel records
+20 ;; ___ Military enlistment examination
+21 ;; ___ Military separation examination
+22 ;; ___ Military post-deployment questionnaire
+23 ;; ___ Department of Defense Form 214 Separation Documents
+24 ;; ___ Veterans Health Administration medical records (VA treatment records)
+25 ;; ___ Civilian medical records
+26 ;; ___ Interviews with collateral witnesses (family and others who have
+27 ;; known the Veteran before and after military service)
+28 ;; ___ Prior audiology reports
+29 ;; ___ Other: ______________________________________
+30 ;; ___ No records were reviewed
+31 ;;^TOF^
+32 ;; 3. Etiology of tinnitus
+33 ;; Select answer below and provide rationale where requested:
+34 ;; ___ The Veteran has a diagnosis of clinical hearing loss, and his or her
+35 ;; tinnitus is at least as likely as not (50% probability or greater) a
+36 ;; symptom associated with the hearing loss, as tinnitus is known to be a
+37 ;; symptom associated with hearing loss
+38 ;; ___ Less likely than not (less than 50% probability) a symptom associated
+39 ;; with the Veterans hearing loss
+40 ;; Rationale: ________________________________________________________
+41 ;; ___ At least as likely as not (50% probability or greater) caused by or a
+42 ;; result of military noise exposure
+43 ;; Rationale: ________________________________________________________
+44 ;; ___ At least as likely as not (50% probability or greater) due to a known
+45 ;; etiology (such as traumatic brain injury)
+46 ;; Etiology and rationale: ___________________________________________
+47 ;; ___ Less likely than not (less than 50% probability) caused by or a result
+48 ;; of military noise exposure
+49 ;; Rationale: ________________________________________________________
+50 ;; ___ Cannot provide a medical opinion regarding the etiology of the
+51 ;; Veteran's tinnitus without resorting to speculation
+52 ;; Reason speculation required: _____________________________________
+53 ;;
+54 ;; 4. Functional impact of tinnitus
+55 ;; NOTE: Ask the Veteran to describe in his or her own words the effects of
+56 ;; disability (i.e. the current complaint of tinnitus on occupational
+57 ;; functioning and daily activities). Document the Veteran's response without
+58 ;; opining on the relationship between the functional effects and the level of
+59 ;; impairment (audiogram) or otherwise characterizing the response. Do not use
+60 ;; handicap scales.
+61 ;;
+62 ;; Does the Veteran's tinnitus impact ordinary conditions of daily life,
+63 ;; including ability to work?
+64 ;; ___ Yes ___ No
+65 ;;
+66 ;; If yes, describe impact in the Veteran's own words: ______________________
+67 ;;
+68 ;; 5. Remarks, if any, pertaining to tinnitus: _________________________________
+69 ;; _____________________________________________________________________________
+70 ;;
+71 ;; Audiologist/clinician signature: _______________________ Date: ______________
+72 ;;
+73 ;; Audiologist/clinician printed name: _________________________________________
+74 ;;
+75 ;; State audiology/examiner license #: _________________________________________
+76 ;;
+77 ;; Physician address: __________________________________________________________
+78 ;;
+79 ;; Phone: ________________________________ Fax: _______________________________
+80 ;;
+81 ;; NOTE: VA may request additional medical information, including additional
+82 ;; examinations if necessary to complete VA's review of the Veteran's application.
+83 ;;^END^
+84 QUIT
