| [613] | 1 | DVBCADCK ;ALB/GTS-557/THM-AUDIO EXAM ; 5/10/91 9:13 AM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | ;
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| 4 | S PG=1,HD91="Department of Veterans Affairs"
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| 5 | S HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
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| 6 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 7 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1305 Worksheet" S HD7="AUDIO",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 8 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,! I '$D(CMBN) W "Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 9 | W !!!!,"Narrative:"
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| 10 | W ?13,"When only pure tone results should be used to evaluate",!?13,"hearing loss, the Chief of the Audiology Clinic should",!?13,"certify that language difficulties or other problems make",!
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| 11 | W ?13,"the use of both pure tone average and speech discrimination",!?13,"inappropriate.",!! I '$D(CMBN) W "A. Audiological history:",!!!!!!!!!!
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| 12 | W $S($D(CMBN):"A. ",1:"B. ") W "Pure tone thresholds at indicated frequencies (air conduction):",!!?16,"dB",?49,"dB",!," ========== RIGHT EAR ========== + ========== LEFT EAR ===========",!
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| 13 | W " A* B C D E A* B C D E",!
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| 14 | W "+------------------------------**+------------------------------**+",!
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| 15 | W "| 500|1000|2000|3000|4000|Average| 500|1000|2000|3000|4000|Average|",!,"+--------------------------------+--------------------------------+",!
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| 16 | W "| | | | | | | | | | | | |",!,"+----+----+----+----+----+-------+----+----+----+----+----+-------+",!!
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| 17 | W "* The pure tone threshold at 500 Hz is not currently used for evaluation",!,"purposes but is used in determining whether or not a ratable hearing",!,"loss exists.",!!,"** - average of B, C, D, and E"
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| 18 | W !!!!,$S($D(CMBN):"B. ",1:"C. ") W "Speech recognition score:",!!," 1. Maryland CNC word list _______ % right ear _______ % left ear",!!
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| 19 | W " 2. W-22 word list _______ % right ear _______ % left ear",!!," (Only if specifically requested by the regional office)",!!!! I $Y>58 D HD2
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| 20 | W $S($D(CMBN):"C. ",1:"D. "),"Note whether tinnitus is present and if so, indicate the following:",!!!! S X1=0
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| 21 | F X="Date/circumstance of onset","Unilateral vs bilateral","Constant vs periodic (indicate frequency)","Severity and effect on daily life","Veteran account of loudness/pitch" S X1=X1+1 W ?5,X1,". ",X," -",!!!! I $Y>58 D HD2
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| 22 | K X1,X
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| 23 | W $S($D(CMBN):"D. ",1:"E. "),"Note whether audiologic results indicate an ear or hearing problem",!,"that requires medical follow-up or a problem, which, if treated, may",!,"cause a change in hearing threshold levels -",!!!!!!!
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| 24 | W $S($D(CMBN):"E. ",1:"F. "),"Summary of audiologic test results:",!!!!!!!!
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| 25 | W $S($D(CMBN):"F. ",1:"G. "),"Recommendations/remarks:",!!!!!!!!
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| 26 | W ?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 27 | W !!?22,"Adequated by: ______________________________",!!?30,"Date: _________________________",!
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| 28 | K LN,LN1,LN2
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| 29 | Q
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| 30 | ;
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| 31 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for "_NAME,!,HD8,!!!
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| 32 | Q
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| 33 | ;
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| 34 | SETIOF ; ** Set device control var's
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| 35 | D HOME^%ZIS
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| 36 | Q
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