DVBCWIO1 ;ALB/JFP AUDIO WKS TEXT - 1 ; 12 FEB 1998
;;2.7;AMIE;**16**;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.
;;
;;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[HDVBCWIO1 2592 printed Dec 13, 2024@01:52 Page 2
DVBCWIO1 ;ALB/JFP AUDIO WKS TEXT - 1 ; 12 FEB 1998
+1 ;;2.7;AMIE;**16**;Apr 10, 1995
+2 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;B. Medical History (Subjective Complaints):
+4 ;; Comment on:
+5 ;; 1. Chief complaint.
+6 ;; 2. Situation of greatest difficulty.
+7 ;; 3. Pertinent service history.
+8 ;; 4. History of military, occupational, and recreational noise
+9 ;; exposure.
+10 ;; 5. Tinnitus - If present, state:
+11 ;; a. Date and circumstances of onset.
+12 ;; b. Whether it is unilateral or bilateral.
+13 ;; c. Whether it is constant or periodic (indicate
+14 ;; frequency).
+15 ;; d. Severity and effect on daily life.
+16 ;; e. Veteran's account of loudness or pitch.
+17 ;;
+18 ;;C. Physical Examination (Objective Findings):
+19 ;; 1. Measure puretone thresholds in decibels at the indicated
+20 ;; frequencies (air conduction):
+21 ;;
+22 ;; = = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = =
+23 ;; A* B C D E ** A* B C D E **
+24 ;; 500|1000|2000|3000|4000|average 500|1000|2000|3000|4000|average
+25 ;; | | | | | | | | | |
+26 ;;
+27 ;; * The puretone threshold at 500 Hz is not used in determining the
+28 ;; evaluation but is used in determining whether or not a ratable
+29 ;; hearing loss exists.
+30 ;; ** The average of B, C, D, and E.
+31 ;;
+32 ;; 2. Speech Recognition Score:
+33 ;; a. Maryland CNC word list _____% right ear _____% left ear.
+34 ;; b. W-22 word list (only if specifically requested by the
+35 ;; regional office). _____% right ear _____% left ear.
+36 ;;
+37 ;; 3. When only puretone results should be used to evaluate hearing
+38 ;; loss, the Chief of the Audiology Clinic should certify that
+39 ;; language difficulties or other problems make the combined use
+40 ;; of puretone average and speech discrimination inappropriate.
+41 ;;
+42 ;;D. Diagnostic and Clinical Tests:
+43 ;; 1. Include results of all diagnostic and clinical tests conducted
+44 ;; in the examination report.
+45 ;;
+46 ;;E. Diagnosis:
+47 ;; 1. Summary of audiologic test results.
+48 ;; 2. Note whether audiologic results indicate an ear or hearing
+49 ;; problem that requires medical follow-up or a problem which, if
+50 ;; treated, might cause a change in hearing threshold levels.
+51 ;;
+52 ;;
+53 ;;Signature: Date:
+54 ;;END
