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1DVBCWIO1 ;ALB/JFP AUDIO WKS TEXT - 1 ; 12 FEB 1998
2 ;;2.7;AMIE;**16**;Apr 10, 1995
3 ;
4TXT ;
5 ;;A. Review of Medical Records:
6 ;;
7 ;;B. Medical History (Subjective Complaints):
8 ;; Comment on:
9 ;; 1. Chief complaint.
10 ;; 2. Situation of greatest difficulty.
11 ;; 3. Pertinent service history.
12 ;; 4. History of military, occupational, and recreational noise
13 ;; exposure.
14 ;; 5. Tinnitus - If present, state:
15 ;; a. Date and circumstances of onset.
16 ;; b. Whether it is unilateral or bilateral.
17 ;; c. Whether it is constant or periodic (indicate
18 ;; frequency).
19 ;; d. Severity and effect on daily life.
20 ;; e. Veteran's account of loudness or pitch.
21 ;;
22 ;;C. Physical Examination (Objective Findings):
23 ;; 1. Measure puretone thresholds in decibels at the indicated
24 ;; frequencies (air conduction):
25 ;;
26 ;; = = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = =
27 ;; A* B C D E ** A* B C D E **
28 ;; 500|1000|2000|3000|4000|average 500|1000|2000|3000|4000|average
29 ;; | | | | | | | | | |
30 ;;
31 ;; * The puretone threshold at 500 Hz is not used in determining the
32 ;; evaluation but is used in determining whether or not a ratable
33 ;; hearing loss exists.
34 ;; ** The average of B, C, D, and E.
35 ;;
36 ;; 2. Speech Recognition Score:
37 ;; a. Maryland CNC word list _____% right ear _____% left ear.
38 ;; b. W-22 word list (only if specifically requested by the
39 ;; regional office). _____% right ear _____% left ear.
40 ;;
41 ;; 3. When only puretone results should be used to evaluate hearing
42 ;; loss, the Chief of the Audiology Clinic should certify that
43 ;; language difficulties or other problems make the combined use
44 ;; of puretone average and speech discrimination inappropriate.
45 ;;
46 ;;D. Diagnostic and Clinical Tests:
47 ;; 1. Include results of all diagnostic and clinical tests conducted
48 ;; in the examination report.
49 ;;
50 ;;E. Diagnosis:
51 ;; 1. Summary of audiologic test results.
52 ;; 2. Note whether audiologic results indicate an ear or hearing
53 ;; problem that requires medical follow-up or a problem which, if
54 ;; treated, might cause a change in hearing threshold levels.
55 ;;
56 ;;
57 ;;Signature: Date:
58 ;;END
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