source: FOIAVistA/tag/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCWHW1.m@ 628

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