DVBCWHW1.m

DVBCWHW1 ;ALB/CMM AUDIO WKS TEXT - 1 ; 6 MARCH 1997

 ;;2.7;AMIE;**12**;Apr 10, 1995

 ;

 ;

TXT ;

 ;;A.  Review of Medical Records:

 ;;

 ;;

 ;;

 ;;B.  Medical History (Subjective Complaints):

 ;;

 ;;    Comment on:

 ;;    1.  Chief Complaint.

 ;;

 ;;

 ;;    2.  Situation of greatest difficulty.

 ;;

 ;;

 ;;    3.  Pertinent service history.

 ;;

 ;;

 ;;    4.  History of military, occupational, and recreational noise exposure.

 ;;

 ;;

 ;;    5.  Tinnitus - If present, state:

 ;;        a.  Date and circumstances of onset.

 ;;

 ;;

 ;;        b.  Whether it is unilateral or bilateral.

 ;;

 ;;

 ;;        c.  Whether it is constant or periodic (indicate frequency).

 ;;

 ;;

 ;;        d.  Severity and effect on daily life.

 ;;

 ;;

 ;;        e.  Veteran's account of loudness or pitch.

 ;;

 ;;TOF

 ;;C.  Physical Examination (Objective Findings):

 ;;

 ;;    1.  Measure puretone thresholds in decibels at the indicated 

 ;;        frequencies (air conduction):

 ;;

 ;;

 ;;= = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = = 

 ;;A*    B    C    D    E    **       A*   B    C   D    E     **

 ;;500|1000|2000|3000|4000|average   500|1000|2000|3000|4000|average

 ;;*  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.

 ;;

 ;;

 ;;    2.  Speech Recognition Score:

 ;;

 ;;        a.  Maryland CNC word list  _______% right ear 

 ;;            ______% left ear.

 ;;

 ;;

 ;;        b.  W-22 word list (only if specifically requested by the 

 ;;            regional office).  ______% right ear     ______% left ear.

 ;;

 ;;

 ;;    3.  When only puretone results should be used to evaluate hearing

 ;;        loss, the Chief of the Audiology Clinic should certify that 

 ;;        language difficulties or other problems make the combined use

 ;;        of puretone average and speech discrimination inappropriate.

 ;;

 ;;

 ;;D.  Diagnostic and Clinical Tests:

 ;;

 ;;    1.  Include results of all diagnostic and clinical tests conducted

 ;;        in the examination report.

 ;;

 ;;

 ;;E.  Diagnosis:

 ;;

 ;;    1.  Summary of audiologic test results.

 ;;    2.  Note whether audiologic results indicate an ear or hearing 

 ;;        problem that requires medical follow-up or a problem which, if

 ;;        treated, might cause a change in hearing threshold levels.

 ;;

 ;;

 ;;Signature:                                   Date:

 ;;END

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCWHW1   2575     printed  Feb 18, 2025@23:18:22                                                                                                                                                                                                    Page 2

DVBCWHW1  ;ALB/CMM AUDIO WKS TEXT - 1 ; 6 MARCH 1997

 +1       ;;2.7;AMIE;**12**;Apr 10, 1995

 +2       ;

 +3       ;

TXT       ;

 +1       ;;A.  Review of Medical Records:

 +2       ;;

 +3       ;;

 +4       ;;

 +5       ;;B.  Medical History (Subjective Complaints):

 +6       ;;

 +7       ;;    Comment on:

 +8       ;;    1.  Chief Complaint.

 +9       ;;

 +10      ;;

 +11      ;;    2.  Situation of greatest difficulty.

 +12      ;;

 +13      ;;

 +14      ;;    3.  Pertinent service history.

 +15      ;;

 +16      ;;

 +17      ;;    4.  History of military, occupational, and recreational noise exposure.

 +18      ;;

 +19      ;;

 +20      ;;    5.  Tinnitus - If present, state:

 +21      ;;        a.  Date and circumstances of onset.

 +22      ;;

 +23      ;;

 +24      ;;        b.  Whether it is unilateral or bilateral.

 +25      ;;

 +26      ;;

 +27      ;;        c.  Whether it is constant or periodic (indicate frequency).

 +28      ;;

 +29      ;;

 +30      ;;        d.  Severity and effect on daily life.

 +31      ;;

 +32      ;;

 +33      ;;        e.  Veteran's account of loudness or pitch.

 +34      ;;

 +35      ;;TOF

 +36      ;;C.  Physical Examination (Objective Findings):

 +37      ;;

 +38      ;;    1.  Measure puretone thresholds in decibels at the indicated 

 +39      ;;        frequencies (air conduction):

 +40      ;;

 +41      ;;

 +42      ;;= = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = = 

 +43      ;;A*    B    C    D    E    **       A*   B    C   D    E     **

 +44      ;;500|1000|2000|3000|4000|average   500|1000|2000|3000|4000|average

 +45      ;;*  The puretone threshold at 500 Hz is not used in determining the 

 +46      ;;evaluation but is used in determining whether or not a ratable 

 +47      ;;hearing loss exists.

 +48      ;;**  The average of B, C, D, and E.

 +49      ;;

 +50      ;;

 +51      ;;    2.  Speech Recognition Score:

 +52      ;;

 +53      ;;        a.  Maryland CNC word list  _______% right ear 

 +54      ;;            ______% left ear.

 +55      ;;

 +56      ;;

 +57      ;;        b.  W-22 word list (only if specifically requested by the 

 +58      ;;            regional office).  ______% right ear     ______% left ear.

 +59      ;;

 +60      ;;

 +61      ;;    3.  When only puretone results should be used to evaluate hearing

 +62      ;;        loss, the Chief of the Audiology Clinic should certify that 

 +63      ;;        language difficulties or other problems make the combined use

 +64      ;;        of puretone average and speech discrimination inappropriate.

 +65      ;;

 +66      ;;

 +67      ;;D.  Diagnostic and Clinical Tests:

 +68      ;;

 +69      ;;    1.  Include results of all diagnostic and clinical tests conducted

 +70      ;;        in the examination report.

 +71      ;;

 +72      ;;

 +73      ;;E.  Diagnosis:

 +74      ;;

 +75      ;;    1.  Summary of audiologic test results.

 +76      ;;    2.  Note whether audiologic results indicate an ear or hearing 

 +77      ;;        problem that requires medical follow-up or a problem which, if

 +78      ;;        treated, might cause a change in hearing threshold levels.

 +79      ;;

 +80      ;;

 +81      ;;Signature:                                   Date:

 +82      ;;END