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VAC PEN 6249: Hearing Loss/Tinnitus Questionnaire

Veterans Affairs Canada uses this questionnaire to confirm a diagnosis of hearing loss or tinnitus when a Veteran applies for disability benefits or is reassessed. It covers medical history, audiogram results, how often tinnitus is present, treatment and complications. VAC accepts a detailed report containing the same information instead, and asks Veterans not to have it completed until VAC has sent specific instructions.

Who completes it

Audiologists, general practitioners, specialists and nurse practitioners may diagnose and assess; physician assistants are accepted only in Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia and Prince Edward Island. Hearing instrument practitioners and specialists may complete it only for an assessment or reassessment after an accepted professional has already made the diagnosis.

Submitting and payment

How to submit it
Return the signed questionnaire, with the audiogram and copies of relevant reports attached, as VAC's instructions to the Veteran direct.
Who pays
The signature block asks the health professional to indicate whether VAC is to be invoiced for completing the questionnaire.

Good to know

  • The audiogram must be no more than 2 years old and show air and bone conduction at 500 to 8000 Hz in both ears, plus speech reception thresholds for both ears.
  • Attach the audiologist's indication of the audiogram's reliability and a narrative interpretation of the results by a registered clinical audiologist or a physician.
  • Tinnitus is rated by ticking one statement, from present less than once a week up to present all day and night and requiring ongoing use of a masking device.
  • Clinic stamps and typed signatures are not valid, and VAC may reject a questionnaire that is unsigned, incomplete or outside the professional's scope of practice.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Questionnaire: Hearing Loss/Tinnitus

Questionnaire médical : Hypoacousie/Acouphène

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Can a hearing instrument practitioner complete PEN 6249?

Only for an assessment or reassessment. VAC accepts hearing instrument practitioners and hearing instrument specialists when an accepted professional, such as an audiologist, physician or nurse practitioner, has already diagnosed the hearing loss or tinnitus. They cannot provide the diagnosis itself.

Can I send a report instead of the PEN 6249 questionnaire?

Yes. The form gives two options: complete the questionnaire, or submit a detailed report that includes all the information it requests. A hearing loss diagnosis still needs the recent audiogram, and copies of relevant consultations, hospital discharge summaries or diagnostic imaging should be attached or forwarded.

Is PEN 6249 available in French?

Yes. VAC publishes the questionnaire in English and French, with the current version dated July 2024; the French title is Questionnaire médical : Hypoacousie/Acouphène. The Veteran's own claim paperwork, such as PEN 923 and VAC 749 for hearing loss claims, is separate.