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Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIREb. WERE THERE ONE OR MORE FREQUENCY(IES) THAT COULD NOT BE TESTED?X YES NO If yes, enter CNT in the box for frequency(ies) that could not be tested, and explain why testing could not be done:Hearing loss exceeds the capabilities of the equipmentc. VALIDITY OF PURETONE TEST RESULTS:X Test results are valid for rating purposes. Test results are not valid for rating purposes (not indicative of organic hearing loss).If invalid, provide reason:d. SPEECH DISCRIMINATION SCORE (MARYLAND CNC WORD LIST)Instructions on pausing: Examiners should pause when necessary during speech discrimination tests, in order to give the Veteran sufficient time to respond. Thiswill ensure that the test results are based on actual hearing loss rather than on the effects of other problems that might slow a Veteran’s response. There are avariety of problems that might require pausing, for example, the presence of cognitive impairment. It is up to the examiner to determine when to use pausing andthe length of the pauses.RIGHT EAR90%LEFT EAR92%e. APPROPRIATENESS OF USE OF SPEECH DISCRIMINATION SCORE (MARYLAND CNC WORD LIST)Right Ear:Is Word Discrimination Score available?X YES NO Word Discrimination Score appropriateness:X Use of speech discrimination score is appropriate for this Veteran. The use of the speech discrimination score is not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent speechdiscrimination scores, etc., that make combined use of puretone average and speech discrimination scores inappropriate.Left Ear:Is Word Discrimination Score available?X YES NO Word Discrimination Score appropriateness:X Use of speech discrimination score is appropriate for this Veteran. The use of the speech discrimination score is not appropriate for this Veteran because of language difficulties, cognitive problems, inconsistent speechdiscrimination scores, etc., that make combined use of puretone average and speech discrimination scores inappropriate.f. AUDIOLOGIC FINDINGSSummary of Immittance (Tympanometry) Findings:RIGHT EARLEFT EARAcoustic immittanceXNormal Abnormal XNormal Abnormal Ipsilateral Acoustic ReflexesNormal Normal XAbnormal Normal Normal XAbnormal Contralateral Acoustic ReflexesUnable to interpret reflexes due to artifactUnable to obtain/maintain sealAUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420XAbnormal Page 3 of 9DOB: 5/7/1945XAbnormal Revised November 21, 2016Last 4 SSN:17 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIRE2. DIAGNOSISRight Ear Normal hearing Conductive hearing loss Mixed hearing lossX Sensorineural hearing loss (in the frequency range of 500-4000 Hz)* Sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies) ** Significant changes in hearing thresholds in service***Left Ear Normal hearing Conductive hearing loss Mixed hearing lossX Sensorineural hearing loss (in the frequency range of 500-4000 Hz)* Sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies) ** Significant changes in hearing thresholds in service***ICD Code:ICD code: H90.41ICD Code:ICD code: H90.42NOTES:*The Veteran may have hearing loss at a level that is not considered to be a disability for VA purposes. This can occur when the auditory thresholds are greaterthan 25 dB at one or more frequencies in the 500-4000 Hz range.** The Veteran may have impaired hearing, but it does not meet the criteria to be considered a disability for VA purposes. For VA purposes, the diagnosis ofhearing impairment is based upon testing at frequency ranges of 500, 1000, 2000, 3000, and 4000 Hz. If there is no HL in the 500-4000 Hz range, but there is HLabove 4000 Hz, check this box.***The Veteran may have a significant change in hearing threshold in service, but it does not meet the criteria to be considered a disability for VA purposes. (Asignificant change in hearing threshold may indicate noise exposure or acoustic trauma.)3. ETIOLOGY Etiology opinion not indicated as: Service connected condition VBA did not request etiologyRight Ear:Was there permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500and 6000 HZ for the right ear?X NO YES Opinion provided for the right ear:X YES NO If present, is the Veteran’s hearing loss at least as likely as not (50% probability or greater) caused by or a result of an event in military service? YESX NO Cannot provide a medical opinion regarding the etiology of the Veteran’s hearing loss without resorting to speculationRationale (Provide rationale for a yes, no answer or speculation reason):Veteran’s hearing thresholds at time of entrance and separation were within normal limits. According to the American College of OccupationalMedicine Noise and Hearing Conservation Committee, “a noise induced hearing loss will not progress once it is stopped.” Therefore it is my opinionthat the Veteran’s current hearing loss is less likely than not related to military noise exposure/acoustic trauma.Did hearing loss exist prior to the service?X NO YES If yes, was the pre-existing hearing loss aggravated beyond normal progression in military service? YES NOProvide rationale for both yes or no:AUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 4 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:18 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIRELeft Ear:Was there permanent positive threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500and 6000 HZ for the left ear?X NO YES Opinion provided for the left ear:X YES NO If present, is the Veteran’s hearing loss at least as likely as not (50% probability or greater) caused by or a result of an event in military service? YESX NO Cannot provide a medical opinion regarding the etiology of the Veteran’s hearing loss without resorting to speculationRationale (Provide rationale for a yes, no answer or speculation reason):The Veteran had a pre-existing hearing loss at 4KHz found on entrance exam of 1965 in his left ear. Discharge exam was unchanged from theEntrance exam. Therefore the hearing loss was not caused by or a result of military service.Did hearing loss exist prior to the service?X YES NO If yes, was the pre-existing hearing loss aggravated beyond normal progression in military service?X NO YES Provide rationale for both yes or no:Veteran's hearing thresholds at time of entrance in 1965 showed a mild loss 4KHz. No change in hearing upon discharge in 1967, therefore theVeteran's current hearing loss is less likely than not related to military noise exposure. A nexus has not been established.4. FUNCTIONAL IMPACT OF HEARING LOSSNote: Ask the Veteran to describe in his or her own words the effects of disability (i.e. The current complaint of hearing loss on occupational functioning and dailyactivities). Document the Veteran’s response without opining on the relationship between the functional effects and the level of impairment (audiogram) or otherwise characterizing the response. Do not use handicap scales.Does the Veteran’s hearing loss impact ordinary conditions of daily life, including ability to work?X YES NO If yes, describe impact in the Veteran’s own words:hard time understanding his wife and grandkids5. REMARKS, IF ANY, PERTAINING TO HEARING LOSS:SECTION 2 - TINNITUS1. MEDICAL HISTORYDOES THE VETERAN REPORT RECURRENT TINNITUS?X YES NO Date and circumstances of onset of tinnitus:during service 1967Onset during basic training, loud explosion. Service treatment records listed tinnitus at discharge.AUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 5 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:19 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIRE2. ETIOLOGY OF TINNITUS Etiology opinion not indicated as: Service connected condition VBA did not request etiology The Veteran has a diagnosis of clinical hearing loss, and his or her tinnitus is at least as likely as not (50% probability or greater) a symptom associated withthe hearing loss, as tinnitus is known to be a symptom associated with hearing loss Less likely than not (less than 50% probability) a symptom associated with the Veterans hearing lossRationale:X At least as likely as not (50% probability or greater) caused by or a result of military noise exposure Rationale:The Veteran was exposed to excessive noise exposure (acoustic trauma) during service. Excessive noise exposure is known to cause tinnitus;therefore the tinnitus is at least as likely as not a result of military noise exposure. At least as likely as not (50% probability or greater) due to a known etiology (such as traumatic brain injury)Etiology and rationale: Less likely than not (less than 50% probability) caused by or a result of military noise exposureRationale: Cannot provide a medical opinion regarding the etiology of the Veteran’s tinnitus without resorting to speculationReason speculation required:AUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 6 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:20 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIRE3. FUNCTIONAL IMPACT OF TINNITUSNOTE: Ask the Veteran to describe in his or her own words the effects of disability (i.e. the current complaint of tinnitus on occupational functioning and dailyactivities). Document the Veteran’s response without opining on the relationship between the functional effects and the level of impairment (audiogram) orotherwise characterizing the response. Do not use handicap scales.Does the Veteran’s tinnitus impact ordinary conditions of daily life, including ability to work?X YES NO If yes, describe impact in the Veteran’s own words:Notices it most when trying to go to sleep, disrupts concentration.4. REMARKS, IF ANY, PERTAINING TO TINNITUS:CERTIFICATION: to the best of my knowledge, the information contained herein is accurate, complete and current.AUDIOLOGIST/CLINICIAN SIGNATURE:DATE:AUDIOLOGIST/CLINICIAN PRINTED NAME:STATE AUDIOLOGY/EXAMINER LICENSE #:PHYSICIAN ADDRESS:PHONE:FAX:NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA’s review of the Veteran’s application.If questions or issues arise upon review of this examination, please contact the VA medical center or dod facility that processed the request for examination.Contractor: Logistics Health IncorporatedPrivacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses(i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has aninterest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension,Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will helpensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny anindividual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is consideredrelevant and necessary to determine.Respondent Burden: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 15minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respondto a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to getinformation on where to send comments or suggestions about this form.AUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 7 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:21 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIREADDITIONAL REMARKSHISTORYa. HOW WOULD YOU BEST DESCRIBE YOUR HEARING? (Check all that apply): Hearing is fine with no concernsX Difficulty hearing in noisy environments X Difficulty hearing in group situations X Able to hear but not clearly X Difficulty hearing from a distance Unable to hearb. DO YOU FEEL THAT YOUR HEARING IS BETTER IN ONE EAR VERSUS THE OTHER?X YES NO If yes, which ear is better?X Left Right c. HAVE HEARING AIDS EVER BEEN RECOMMENDED?X NO YES If yes, have they been worn?If yes, which ear? Yes No Right Left Bothd. HAVE YOU EVER HAD EAR SURGERY?X NO YES If yes, which ear? Right Left BothWhat type of surgery, describe:e. HAVE YOU BEEN DIAGNOSED WITH AND/OR RECEIVED ANY OF THE FOLLOWING? (Check all that apply): Otosclerosis Labyrinthitis Permanent hearing loss Bell’s palsy Cholesteatoma Meniere’s disease Ossicular dislocation/fixation Sudden hearing loss Barotrauma Acoustic neuroma Meningitis MeaslesX Cancer X Radiation/chemotherapy Long term IV antibiotics Head traumaPlease describe the marked diagnoses:Treated for prostate cancer with radiation in 2015.FAMILY HISTORY OF HEARING LOSSa. PLEASE DESCRIBE RELEVANT FAMILY HISTORY OF HEARING LOSS:NoneAUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 8 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:22 of 23

Hearing Loss and Tinnitus DBQ SampleHEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIREADDITIONAL REMARKSPOST SERVICE HISTORY OF NOISE EXPOSUREa. HAVE YOU BEEN EXPOSED TO LOUD NOISES, RECENTLY OR POST SERVICE? (Check all that apply):X Fire Arms Aircraft NoiseX Farm Equipment Heavy Equipment Power Tools Motorcycles/recreational vehicles Other; specify:Describe any marked above:Recreational hunting and was a farmer for more than 30 years.AUDIO - Hearing Loss and Tinnitus DBQName: Veteran Johnny D 2016 Logistics Health Incorporated. All Rights Reserved. Proprietary and Confidential. 2017 Logistics Health Incorporated (LHI). All rights reserved. 20170420Page 9 of 9DOB: 5/7/1945Revised November 21, 2016Last 4 SSN:23 of 23

Hearing loss exceeds the capabilities of the equipment X 90 92 X X X X X X X Veteran Johnny D 5/7/1945. 2017 o oo 20170420 Hearing Loss and Tinnitus DBQ Sample 18 of 23 HEARING LOSS AND TINNITUS DISABILITY BENEFITS QUESTIONNAIRE AUDIO - Hearing Loss and Tinnitus DBQ Page 4 of 9 Revised November 21, 2016