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 ---[H[J[2J[HDVBCWHW1 2575 printed Apr 09, 2024@20:47:36 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
