Hearing Loss and Tinnitus worksheet

4010 AUDIO

MEDICAL HISTORY for Hearing Loss (Subjective Complaints):

Claimant does not wish to pursue this claim.

1. What is the main complaint?

2. When is it most difficult for you to hear?

3. Please describe your history of noise exposure in the three following areas:

4.Any family history of the following?

5.Any ringing in the ears?
Yes
No

If yes, indicate the following:

a. Date
unknown


b. When and where it began
unknown


c.Whether it is unilateral or bilateral:

If recurrent, how often does ringing occur?

If recurrent, how long does the ringing last?

Physical Examination (Objective Findings):

1. Middle ear status:

2. Tympanometry results:

3. Acoustic reflex test results:

Diagnostics:

Name of audiologist who performed audio testing:

Credentials for this person :

1. Audiogram Results:

***Puretone thresholds should not exceed 105 decibels or the tolerance level.***

Do any pure tone air conduction thresholds at 500, 1000, 2000, 3000, and

4000 Hz differ by 20 dB or more between the two ears?

If yes, administer a Stenger test and provide results below:

Are any air conduction thresholds poorer than 15 dB HL?
yes
no

Provide bone conduction thresholds below:

2. Speech Recognition Score: Maryland CNC word list results:

***Puretone thresholds should not exceed 100 decibels or the tolerance level.***

% right ear
% left ear.

3. Spondee Thresholds (Speech Reception Thresholds):

Right ear:
 
Left ear:

4. If only puretone results should be used to evaluate hearing loss,
please state specifically whether language difficulties or other problems make

the combined use of puretone average and speech discrimination inappropriate:

[n/a]

5. In cases where there is poor inter-test reliability and/or positive Stenger

test results, obtain and report estimates of hearing thresholds using a

combination of behavioral testing, Stenger interference levels, and electrophysiological tests.

[n/a]

Behavioral testing results are

Stenger
interference levels results are

Electrophysiological tests results are

Diagnosis:

For VA purposes, impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hz is 40 dB HL or greater; or when the auditory thresholds for at least three of these frequencies are 26 dB HL or greater; or when speech recognition scores are less than 94%.

Is there any hearing loss present? 
yes
no

If yes, is it
bilateral
right ear only
eft ear only

Please describe the hearing loss for the RIGHT ear:

Please describe the hearing loss for LEFT ear:

Based on audiologic results, is any medical follow-up needed for an ear or hearing problem? 
yes
no

If yes, please explain:

Will the hearing loss, if treated, cause a change in hearing threshold levels?
yes
no

Is there any tinnitus?
yes
no

If yes, is the tinnitus as likely as not a symptom associated with the hearing loss?
yes
no

If tinnitus is associated with a condition other than hearing loss,

is referral to another specialty provider needed to determine etiology?
yes
no

If yes, state specialty needed:

Please state the effect of the condition on the claimant’s usual occupation and daily activities.

ADDITIONAL COMMENTS AS NEEDED

Have all abnormalities found on exam and diagnostics been addressed?
Yes
No

discuss below and state whether abnormality is mild, moderate, life threatening or otherwise extremely serious