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tinnitus Fast Letter 07-10-07
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DEPARTMENT OF VETERANS AFFAIRS
Veterans Benefits Administration
Washington, D.C. 20420
April 24, 2007 In Reply Refer To: 211D
Fast Letter 07-10
Director (00/21)
All VA Regional Offices and Centers
SUBJECT: Revised Disability Examination Worksheets
Revised disability examination worksheets for Audio; Ear Disease; Hand, Thumb and Fingers; Feet; Mental Disorders; Eating Disorders; Esophagus and Hiatal Hernia; Intestines; and Stomach, Duodenum, and Peritoneal Adhesions have been released nationally to VA Medical Centers for C&P examiner use.
These worksheets are changed in the following significant ways:
Audio and Ear Disease
The Audio examination worksheet no longer requires frequency and duration for tinnitus. The examiner only needs to state whether tinnitus is persistent or recurrent.
On the Audio examination worksheet, the request for an opinion about the etiology of tinnitus has been removed. If an opinion about etiology is required for a specific veteran, the regional office must request it.
On the Ear Disease examination worksheet, questions have been added about history of hospitalizations, surgery, noise exposure and ear trauma.
On both examination worksheets, examiners are asked to describe effects on occupational functioning and daily activities.
Hand, Thumb and Fingers
Under history, questions about hospitalizations, surgery, trauma and neoplasm have been added.
Examiners are asked to describe current symptoms and effects on occupational functioning and daily activities.
On physical examination, the requirement for passive range of motion has been removed.
Feet
Under history, questions about neoplasm have been added.
On physical examination, all requirements for range of motion of the toes; active, passive and after repetition have been removed.
On physical examination, assessment of posture in various positions has been removed.
Mental Disorders and Eating Disorders
The credentials of examiners who VBA and VHA recently agreed can perform these types of examinations are listed.
On a Mental Disorders examination, the examiner is expected to select the appropriate assessment of the veteran from the list provided and support the assessment with examples.
Esophagus and Hiatal Hernia
Under history, questions about hospitalizations, surgery, trauma and neoplasm have been added as well as the effects of the condition on occupational functioning and daily activities.
Under diagnostic tests, if there is a history of bleeding (past 12 months) or signs of anemia, a hemoglobin/hematocrit is required.
Intestines
Under history, questions about hospitalizations, surgery, trauma and neoplasm have been added as well as effects of the condition on occupational functioning and daily activities.
Under history, for ulcerative colitis, the number of attacks per year has been added as a requirement.
Under diagnostic tests, if there are signs of anemia, a hemoglobin/ hematocrit is required.
Scars
Under history, the treatment used and response to treatment has been removed.
Stomach, Duodenum, and Peritoneal Adhesions
Under history, questions about hospitalizations, surgery, trauma and neoplasm have been added as well as effects of the condition on occupational functioning and daily activities.
Under diagnostic tests, if there is a recent history (past 12 months) of hematemesis, melena or signs of anemia, a hemoglobin/hematocrit is required.
The following worksheets will be released in approximately 8 weeks: Bones; Chronic Fatigue Syndrome; Cranial Nerves; Cushing’s Syndrome; Eye; Fibromyalgia; HIV-Related Illness; Liver, Gall Bladder, and Pancreas; Lymphatic Disorders; Nose, Sinus, Larynx, and Pharynx; and Rectum and Anus.
These worksheets have been changed in the following significant ways:
Bones
Under history, questions about hospitalizations, surgery and neoplasm have been added.
If a joint is involved, the examiner is referred to the Joint worksheet.
Chronic Fatigue Syndrome
Under history, a question about hospitalizations has been added.
Under history, questions about debilitating fatigue, incapacitating episodes and cognitive impairment have been added.
A cursory physical examination has been added.
Cranial Nerves
Under history, the question about flare-ups has been deleted.
Under history, the examiner is asked to comment on onset, course since onset and current symptoms.
Under history, questions about hospitalization, surgery, neoplasm and trauma have been added.
Under history, a question about effects on occupational functioning and daily activities has been added.
Cushing’s syndrome
Under history, questions about hospitalizations, surgery, and neoplasm have been added.
Under history, a question about effects on occupational functioning and daily activities has been added.
Diagnostic and Clinical tests are only to be performed if not of record or to confirm a diagnosis.
Eye
Under history, questions about hospitalizations, surgery, and trauma have been added.
Under history, a specific question for congestive or inflammatory glaucoma has been added.
Under physical examination, a specific question about the ability to wear a prosthesis after enucleation has been added.
Fibromyalgia
Under history, a question about hospitalizations has been added.
HIV-Related Illness
Under history, questions about hospitalizations, surgery and neoplasm have been added.
Liver, Gall Bladder, and Pancreas
Under history, a question about effects on occupational functioning and daily activities has been added.
Lymphatic Disorders
Under history, a question about hospitalizations and surgery has been added.
Under history, a question about effects on occupational functioning and daily activities has been added.
A focused physical examination has been added.
Nose, Sinus, Larynx, and Pharynx
Under history, for chronic sinusitis, a question about incapacitating and non-incapacitating episodes per year has been added.
Under history, a question about effects on occupational functioning and daily activities has been added.
Under history, questions about neoplasm have been added.
Under physical examination, the examination for larynx and pharynx has been added.
Rectum and Anus
Under history, questions about hospitalizations, surgery, trauma, and neoplasm have been added.
Under history, a question about effects on occupational functioning and daily activities has been added.
Under Diagnostic and Clinical tests, the examiner is asked to obtain a CBC if there is a history of bleeding, signs of anemia or chronic infection.
If you have any questions about this letter, please contact Vicki Milton, M.D., at (202) 273-9646 or by e-mail.
/S/
Bradley G. Mayes
Director
Compensation & Pension Service
USAF 1980-1986, 70% SC PTSD, 100% TDIU (P&T)
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