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1DVBCWHW1 ;ALB/CMM AUDIO WKS TEXT - 1 ; 6 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;
9 ;;
10 ;;B. Medical History (Subjective Complaints):
11 ;;
12 ;; Comment on:
13 ;; 1. Chief Complaint.
14 ;;
15 ;;
16 ;; 2. Situation of greatest difficulty.
17 ;;
18 ;;
19 ;; 3. Pertinent service history.
20 ;;
21 ;;
22 ;; 4. History of military, occupational, and recreational noise exposure.
23 ;;
24 ;;
25 ;; 5. Tinnitus - If present, state:
26 ;; a. Date and circumstances of onset.
27 ;;
28 ;;
29 ;; b. Whether it is unilateral or bilateral.
30 ;;
31 ;;
32 ;; c. Whether it is constant or periodic (indicate frequency).
33 ;;
34 ;;
35 ;; d. Severity and effect on daily life.
36 ;;
37 ;;
38 ;; e. Veteran's account of loudness or pitch.
39 ;;
40 ;;TOF
41 ;;C. Physical Examination (Objective Findings):
42 ;;
43 ;; 1. Measure puretone thresholds in decibels at the indicated
44 ;; frequencies (air conduction):
45 ;;
46 ;;
47 ;;= = = = =RIGHT EAR= = = = = = = = = = = = = LEFT EAR = = = = = =
48 ;;A* B C D E ** A* B C D E **
49 ;;500|1000|2000|3000|4000|average 500|1000|2000|3000|4000|average
50 ;;* The puretone threshold at 500 Hz is not used in determining the
51 ;;evaluation but is used in determining whether or not a ratable
52 ;;hearing loss exists.
53 ;;** The average of B, C, D, and E.
54 ;;
55 ;;
56 ;; 2. Speech Recognition Score:
57 ;;
58 ;; a. Maryland CNC word list _______% right ear
59 ;; ______% left ear.
60 ;;
61 ;;
62 ;; b. W-22 word list (only if specifically requested by the
63 ;; regional office). ______% right ear ______% left ear.
64 ;;
65 ;;
66 ;; 3. When only puretone results should be used to evaluate hearing
67 ;; loss, the Chief of the Audiology Clinic should certify that
68 ;; language difficulties or other problems make the combined use
69 ;; of puretone average and speech discrimination inappropriate.
70 ;;
71 ;;
72 ;;D. Diagnostic and Clinical Tests:
73 ;;
74 ;; 1. Include results of all diagnostic and clinical tests conducted
75 ;; in the examination report.
76 ;;
77 ;;
78 ;;E. Diagnosis:
79 ;;
80 ;; 1. Summary of audiologic test results.
81 ;; 2. Note whether audiologic results indicate an ear or hearing
82 ;; problem that requires medical follow-up or a problem which, if
83 ;; treated, might cause a change in hearing threshold levels.
84 ;;
85 ;;
86 ;;Signature: Date:
87 ;;END
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