Ear Disease

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records: Indicate whether the C-file was reviewed.

B. Medical History (Subjective Complaints):

1. Describe history of hearing loss, tinnitus, vertigo, balance or gait problems, discharge, pain, pruritus. State onset and frequency and duration of each, if not constant.
2. Describe current or past treatment, response and side effects for ear conditions.
3. History of hospitalization or surgery (location, date if known and reason or type of surgery).
4. History of military, occupational and recreational noise exposure.
5. History of trauma to the ear(s).
6. Describe effects on occupational functioning and activities of daily living.
7. If a neoplasm of the ear is or was present:

1. State date of confirmed diagnosis, diagnosis.
2. Benign or malignant.
3. State date of the last surgical, X-ray, antineoplastic chemotherapy, radiation, or other therapeutic procedure.
1. State expected date treatment regimen is to be completed.
2. If treatment is already completed, provide date of last treatment.
3. If treatment is already completed, fully describe residuals.

C. Physical Examination (Objective Findings):

1. Conduct an external and otoscopic examination. Address each of the following and describe current findings, including abnormalities of size, shape, or form:

1. Auricle. Any deformity? If there is tissue loss, state whether it is one-third or more of auricle.
2. External canal - describe any edema, scaling, discharge.
3. Tympanic membrane.
4. The tympanum.
5. Mastoids. Discharge? Evidence of cholesteatoma?
6. State all conditions secondary to ear disease, such as disturbance of balance, upper respiratory disease, hearing loss, etc.

2. State whether an active ear disease is present.
3. Infections of the middle or inner ear. Is there suppuration? Effusion? Are aural polyps present?
4. For peripheral vestibular disorders, state the specific diagnosis and its basis, whether there is dizziness and how often, and whether a staggering gait occurs and how often.
5. For Meniere’s syndrome, state the symptoms, including the frequency of attacks of vertigo and cerebellar gait. Is tinnitus present? If so, how frequently and what is its duration? Is there hearing loss? (See audio worksheet.)
6. Describe any complications of ear disease that are present.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: