| Applicant ________________________________ SS# ________________________________ Adjudicator ________________________________ |
NOTICE TO PHYSICIAN: Medical information is needed to establish your patient's eligibility under the disability provisions of the Social Security Act. Please refer to the Physician's Handbook "Disability Evaluation under Social Security" for specific references. This form is for your convenience; however, if you prefer, it is acceptable to submit your report on your own letterhead with photocopies of hospital summaries or other reports attached. |
| 1) Date of most recent examination: ______________________________ 2) Current diagnosis: ______________________________ 3) Please give date(s) and results of otolaryngologic exam: Date(s): Results: 4) Loss of hearing: a. What is the hearing threshold at the following frequencies: |
| Right ear without hearing aid | Right ear with hearing aid | Left ear without hearing aid | Left ear with hearing aid | |||
| 500hz | _________ | _________ | _________ | _________ | ||
| 1000hz | _________ | _________ | _________ | _________ | ||
| 2000hz | _________ | _________ | _________ | _________ | ||
| 3000hz | _________ | _________ | _________ | _________ | ||
| b. Bone conduction: | ||||||
| Right ear | Left ear | |||||
| 500hz | _________ | _________ | ||||
| 1000hz | _________ | _________ | ||||
| 2000hz | _________ | _________ | ||||
c. Does the audiometer meet the standards of the American National Standards Institute for air and bone conducted stimuli? Yes ( ) No ( ) | ||||||
| 5) Speech discrimination test results: Date __________________ | ||||||
| a. Right ear without hearing aid: ______________ with hearing aid: ______________ | Left ear without hearing aid: ____________ with hearing aid: ______________ | |||||
b. Speech reception threshold: _______________________________ | ||||||
| c. Intensity at which discrimination scores were obtained _______________________ | ||||||
| d. Type of test material used ___________________________________________ | ||||||
| e. Were visual clues used: Yes ______________ No ______________ | ||||||
6) Please provide audiogram if available. | ||||||
7) Please describe patient's speech: detailing audibility, intelligibility, and rate of speech and ease of speech flow: | ||||||
8) Has the claimant attended a special school for the hearing impaired?. If so, please indicate the name, location and dates attended, if known: | ||||||
9) Is there evidence of disturbance of labyrinthine-vestibular function? | ||||||
| a. Please describe the frequency, severity, accompanying signs and symptoms and duration of vertiginous episodes: | ||||||
| b. Describe the precipitating factors of attacks: | ||||||
| c. Factors which relieve attacks (i.e. medication, position): | ||||||
| d. Medication and dosage: | ||||||
| e. Response to therapy: | ||||||
| f. Tinnitus: present ( ) absent ( ) | ||||||
| g. Progressive loss of hearing (documented by audiograms of possible): Yes ( ) No ( ) State degree of loss: | ||||||
| h. Date(s) and results of caloric or other vestibular tests: | ||||||
| i. Dates and results of skull and temporal bone x-rays (include copies, if available): | ||||||
| j. Date(s) and results of any other tests (i.e. polytomograms, contract radiographic). Please submit copies if available: | ||||||
| 10) Please describe any other impairments or coniditions not covered by the questions on this form: | ||||||
| This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 20CFR404.1601 et. seq. Disclosure of this information is VOLUNTARY. This form has been approved by the State Forms Management Center. | ||||||
| _________________________________________________________________________ (Physican's signature and title) (Date) (Telephone number) | ||||||
| _________________________________________________________________________ (Street Address) (City) (State) (Zip Code) DF-592 IL:488-1782 | ||||||