Medical/Professional Relations

Consultative Examinations: A Guide for Health Professionals

Part IV - Adult Physical Consultative Examination (CE) Report Content

The following are guidelines to provide minimum content for CE reports for adult claimants. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

General Consultative Examination and Report

  1. Identification

    1. The CE provider will include the claimant's name, date of birth and/or claim number and;
    2. The CE provider will indicate that the claimant provided proof of identity by showing a valid and current government photographic identification (for example, U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, student or school ID, etc.); or provide a physical description of the claimant to verify that the person being examined is the claimant, except if the claimant’s medical source with a treating relationship is the CE provider.
  2. Medical history

    1. Longitudinal Medical History
      1. The CE provider will cite and describe the medical records and any other documents reviewed during the course of the evaluation, and
      2. The CE provider will identify the person(s) providing the oral medical history, as well as an assessment of the validity and reliability of such information.
    2. Current Medical History

      The CE provider will describe and discuss as appropriate:

      1. The primary impairment(s) alleged as the reason for not working. This information must be in a narrative, rather than a “questionnaire” or “check-off” form, and pertinent descriptive statements by the claimant should be recorded in the claimant’s own words. This description must include:
        1. History of the onset and progress of the disorder(s) and/or impairment(s);
        2. The claimant’s statement of current symptoms;
        3. Type and resultant effect of any treatment;
        4. Factors which increase the problem or impairment or that may provide relief; and
        5. The claimant’s typical daily activities and the claimant’s description of how their disorder(s) and/or impairment(s) limit their ability to function.
      2. Dates and results of relevant hospitalizations, surgical operations, and diagnostic procedures (for example, audiometry, tympanography, MRI).
    3. Past Medical History

      The CE provider will describe and discuss, as appropriate, any other significant past illnesses, injuries, operations, hospitalizations, and diagnostic procedures with dates of the events, and when possible, the names of the treatment providers or facilities.

    4. Current Medications

      The CE provider will list the name, dose, and frequency of
      medication(s), including both beneficial and adverse effects, and plans for continued drug administration, schedule, and extent of any therapy.

    5. Review of systems

      The CE provider will describe and discuss other symptoms the claimant has experienced relative to any specific organ systems; and the pertinent negative findings considered in making a differential diagnosis of the current illness or in evaluating the severity of this or any other alleged impairment.

    6. Social history

      The CE provider will include pertinent findings about use of tobacco products, alcohol, and nonprescription drugs, etc., as well as relevant work history such as occupations with exposure to hazards.

    7. Family history

      The CE provider will include the relevant information.


  3. Physical examination and other objective findings

    1. Physical examination

      The CE provider will describe and discuss as appropriate:

      1. General observations, such as how the claimant arrived at the examination, whether they were alone or accompanied, the distance they traveled, and if they arrived by automobile, who drove;
      2. General appearance (including any obvious vision or hearing loss, and facial, skeletal, or other abnormalities);
      3. Blood pressure, pulse rate and rhythm, respiratory rate;
      4. Nutritional status (including height and weight without shoes, including the presence and impact of obesity, if appropriate);
      5. Behavior (such as cooperativeness and effort on testing, as appropriate); and
      6. A thorough and complete physical examination, with aspects of the examination focusing on the claimant’s major and minor complaints in detail, describing both pertinent positive and negative findings.
    2. Laboratory and imaging tests (for example, x-ray)

      1. The CE provider will obtain only after proper authorization from the DDS.
      2. The CE provider will provide an interpretation of laboratory and imaging tests.

        1. The CE provider will provide interpretation that takes into account, and correlates with, the history and physical examination findings.
        2. If the interpretation is provided separately, or if a medical source other than the person signing the CE report is providing the formal interpretation of the results, the report sheet should state the interpreting medical source’s name and address.

  4. Medical opinion

    1. The medical source should provide a medical opinion

      The CE provider will assess the claimant’s ability to perform the demands of work activities, and any limitations based upon the claimant’s medical history, medical signs and observation during the examination, and results of relevant laboratory and imaging tests.

      1. The CE provider will specify the nature and extent of the condition(s) or disorder(s);
      2. The CE provider will discuss any apparent discrepancies in the medical history and/or in the examination findings; and
      3. The CE provider will specify any limitations in functioning that result from the condition(s) or disorder(s), including:

        1. Lifting, carrying, pushing, pulling;
        2. Sitting, standing, walking;
        3. Postural (for example: climbing, stooping, bending, balancing, crawling, kneeling and/or crouching);
        4. Fine or gross motor skills (for example; handling, fingering, gripping, and/or feeling);
        5. Overhead, lateral, and forward reaching:
        6. Vision, hearing, and speech; and
        7. Environmental exposures (for example: extreme heat, extreme cold, wetness, humidity, noise, vibration, and hazards).

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Report content by Specific Impairment

Musculoskeletal Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with musculoskeletal disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content
  2. The CE report guidelines for adult musculoskeletal disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  3. Report content specific to musculoskeletal disorders

  4. The CE provider will use the specific requirements below to complete the CE report for a musculoskeletal disorder.

    1. Current medical history

    2. The CE provider will describe and discuss, as appropriate:

      1. Character, location, and radiation of pain;
      2. Factors that incite and relieve the pain as well as attempted treatment modalities such as medication, physical therapy, and/or surgical intervention, as well as their effect;
      3. Any history of fractures of bones (traumatic), dates and frequency of fractures, imaging (if available), and the status of any fractures (including clinical evidence of union or non-union) at the time of the examination;
      4. Symptoms of weakness, other motor loss, and/or any sensory abnormalities; and
      5. Dates and results of any relevant diagnostic procedures, such as x-rays, myelography, CT scan, MRI, and radio-nuclear bone scan.
    3. Physical examination
    4. The CE provider will describe and discuss, as appropriate:

      1. Any apparent abnormalities such as gait or the need for any type of assistive device:

        1. If the claimant uses an assistive device(s), note the type of, and medical need for, the device, the medical impairment the device is needed for, and examination findings that support the medical need for the assistive device. Also, note whether the assistive device was prescribed, how frequently it is used, the date it was prescribed, and the medical source who prescribed it.
        2. For lower extremity assistive devices, describe the claimant’s gait with and without use of the device.
        3. Describe the claimant's ability to bend, squat, arise from a squatting position, tandem walk, walk on their heels and toes, get up from a chair, get on and off the examining table, and dress and undress.
      2. Extremities and peripheral joints:

        1. Active and passive range of motion. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;
        2. Effusion;
        3. Peri-articular swelling;
        4. Pain, if any, and its distribution;
        5. Tenderness;
        6. Redness or heat;
        7. Thickening;
        8. Structural deformities;
        9. Instability;
        10. Grip, pinch, ability to close the fist or perform fine and gross manipulations, and strength (measured either by dynamometer or 0-5 scale);
        11. Extremity strength (measured either by dynamometer or 0-5 scale);
        12. Atrophy; and
        13. Ability to use, and effective use of, any orthoses.
      3. Spine

        1. Distribution of pain, tenderness, and sensory and/or motor loss;
        2. Muscle spasms, when present;
        3. Intensity and symmetry of deep tendon reflexes;
        4. Active range of spinal motion;
        5. When the lumbar spine is an issue, straight-leg raising (lumbar spine, both sitting and supine); and
        6. When the cervical spine is an issue, provocation test for radiculopathy, such as the Spurling Test (cervical spine).
      4. Amputated extremities:

        1. Description of stump, including integrity of skin flap;
        2. Tenderness; and
        3. Ability to use, and effective use of any prostheses, as well as the functional level of the contralateral extremity. It is not necessary to evaluate the individual’s ability to walk without the prostheses in place.
      5. Fractures of bones of extremities or pelvis:

        1. Review of imaging such as x-rays or MRI; and
        2. Clinical evidence of union or non-union.
      6. Soft tissue injuries/burns:

        1. Nature and extent of the injury;
        2. Skin sensitivity; and
        3. Effect the injury has on joint motion.

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Special Senses & Speech Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with special senses and speech disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for adult special senses and speech disorders CE report content
  2. The CE report guidelines for adult special senses and speech disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  3. Report content specific to visual disorders
  4. The CE provider will use the specific requirements below to complete the CE report for a visual disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Character and severity of visual loss; and
      2. Dates and results of relevant diagnostic procedures, such as imaging studies, visual acuity testing, and visual field testing.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Best corrected visual acuity for each eye, and the lens correction for each eye (manifest refraction, correction of own lenses is not sufficient for "best corrected");

        1. If there is a loss of visual acuity, document the cause of the loss.
        2. If the vision loss is due to a cortical visual disorder, it must be confirmed by documenting the cause of the brain lesion.
      2. Examination of pupils, external examination, and extraocular motions;
      3. Visual field -- confrontation visual fields;

        1. If confrontation fields are not normal, or if there is a history of glaucoma or other conditions resulting in visual field loss, visual fields are needed;
        2. Confrontation fields are acceptable evidence that the fields are normal. Restricted fields must be confirmed either by acceptable automated static threshold perimetry, measuring the central 24 to 30 degrees of the visual field performed on an acceptable perimeter (acceptable tests include the Humphrey Field Analyzer (HFA) 30-2, Octopus 32, Octopus 30-2, and HFA 24-2); or an acceptable manual or automated kinetic perimetry (for example, Goldmann perimetry);
        3. Include a printout of any visual field testing (perimetry) results; and
        4. If there is a loss of visual fields, document the cause of the loss.
      4. Intraocular pressure for each eye;
      5. Slit lamp examination: include detailed description of the cornea and lens;
      6. Fundus examination: include detailed description of the discs, vessels, maculae, and peripheral retina; and
      7. Describe any observed visual behaviors, such as the ability to navigate in the office, reaching for items handed to them, using a cellphone in the waiting room, etc.
  5. Report content specific to hearing loss

    The CE provider will use the specific requirements below to complete the CE report for a hearing disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Character and severity of hearing loss; and
      2. Dates and results of relevant diagnostic procedures, such as audiometry, typanography, and MRI.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Examination of the ears, nose, and throat;
      2. An otologic examination;

        1. The external ears (pinnae and external ear canals) and the tympanic membranes; and
        2. Any middle ear abnormalities.
      3. Hearing loss;

        1. The condition that causes the hearing loss, including any related speech impairments; and
        2. Whether the hearing loss is sensorineural, conductive, or mixed.
      4. Claimants without a cochlear implant(s); and

        1. Pure tone air conduction and bone conduction testing, speech reception threshold (SRT) testing, and word recognition testing;
        2. Testing must be done in a sound-treated booth or room;
        3. Testing must be done in accordance with the most recently published standards of the American National Standards Institute (ANSI);
        4. Each ear must be tested separately; and
        5. If the SRT is not within 10dB of the average pure tone air conduction thresholds at 500, 1,000, and 2,000 Hz, document the medical basis for the discrepancy.
      5. Claimants with a cochlear implant(s)

        1. Sentences presented at 60 dB hearing level and without any visual cues;
        2. In a quiet sound field; and
        3. With the cochlear implant in place, functioning properly, and adjusted to the claimant’s normal settings.

  6. Report content specific to labyrinthine-vestibular disorders

    The CE provider will use the specific requirements below to complete the CE report for a labyrinthine-vestibular disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Episodes of vertigo, including frequency, severity, and duration of the attacks;
      2. Nausea and vomiting;
      3. Ataxia;
      4. Tinnitus;
      5. Progressive hearing loss; and
      6. Dates and results of relevant diagnostic procedures such as x-rays, CT scan, MRI, or radio-nuclear bone scan.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Examination of the ears, nose, and throat;
      2. An otologic examination;

        1. Describe the external ears (pinnae and external ear canals) and the tympanic membranes; and
        2. Assess any middle ear abnormalities.
      3. Report the presence of absence of nystagmus, Romberg results, and cerebellar signs;
      4. The results of any caloric and other vestibular tests; and
      5. Pure tone audiometry showing progressive hearing loss with special examinations such as Bekesy audiometry.
  7. Report content specific to speech sound disorders

    The CE provider will use the specific requirements below to complete the CE report for a speech sound disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Duration, onset, and cause of the speech sound disorder(s), if known;
      2. Dates and results of any relevant diagnostic procedures or testing; and
      3. Treatment modalities, dates of treatments, and responses to treatments.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. The claimant's ability to produce and sustain speech;
      2. The use of, or need for, any voice modulation or amplification devices;
      3. The claimant's speech articulation and volume for sustained speech; and
      4. The presence of abnormalities such as aphasia, dysarthia, stuttering, or involuntary vocalizations.

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Respiratory Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with respiratory disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult respiratory disorders

    The CE report guidelines for adult respiratory disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.


  2. Report content specific to respiratory disorders

    The CE provider will use the specific requirements below to complete the CE report for a respiratory disorder:

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Dyspnea at rest and/or with exertion;
      2. How much activity causes dyspnea (for example, distance the claimant can walk and how many flights of stairs they can climb before resting);
      3. Palpations, wheezing, cough, sputum production, chest discomfort, paroxysmal nocturnal dyspnea, and orthopnea;
      4. Characteristics of severe respiratory attack or persistent pulmonary infection;
      5. History of hospital admissions or emergency department visits; and
      6. Episodic disorders, such as asthma:

        1. Onset and precipitating factors;
        2. Frequency and intensity;
        3. Duration;
        4. Mode of treatment and response;
        5. Compliance with therapy including frequency of inhaler use; and
        6. Description of a severe attack.
    2. Social history

      The CE provider will describe and discuss, as appropriate, any tobacco use, substance use, or any employment history relevant to the condition such as exposure to fibrotic agents, chemicals, or irritants.

    3. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Assistive devices: presence of tracheostomy, central venous catheter, or gastrostomy;
      2. The presence of, or need for supplemental oxygen and for what period (for example, all the time, with exercise, at night, etc.);
      3. Respiratory rate: whether respirations are labored, and use of accessory muscles of respiration;
      4. Lungs:

        1. Occurrence of cough, audible wheezing, pallor cyanosis, hoarseness, clubbing of fingers, chest wall deformity, and any abnormal curvature of the spine;
        2. Whether there is prolongation of the expiration phase or respiration;
        3. Quality of breath sounds (or air exchange), whether normal or diminished;
        4. Presence of adventitious sounds (such as wheezing, rhonchi, or rales); and
        5. Diaphragmatic motion.
      5. Heart and vascular:

        1. Description of heart sounds;
        2. Presence of any lifts, heaves, or thrills;
        3. Heart size;
        4. Point of maximal impulse of cardiac apex;
        5. Presence of any murmurs, rubs, or gallops;
        6. Presence and location of any bruits;
        7. Distention of neck veins; and
        8. Presence, type, and extent of any peripheral edema and any associated skin discoloration or ulceration.
      6. Pulmonary Function Tests

        The CE provider will obtain pulmonary function tests only after receiving proper authorization from the DDS.

        1. Spirometry: Perform as specified in section 3.00E of the respiratory listings (see https://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm).
        2. Diffusing capacity of the lungs (DLCO) test: Perform as specified in section 3.00F of the respiratory listings listings (see https://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm).
        3. Arterial blood gas (ABG) test: Perform as specified in section 3.00G of the respiratory listings listings (see https://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm).

        4. Pulse oximetry: Perform as specified in section 3.00H of the respiratory listings listings (see https://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm).

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Cardiovascular Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with cardiovascular disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult cardiovascular disorders

    The CE report content guidelines for adult cardiovascular disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.


  2. Report content specific to cardiovascular disorders

    The CE provider will use the specific requirements below to complete the CE report for a cardiovascular disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Dyspnea, orthopnea, fatigue, and exercise intolerance;
      2. Chest pain (angina, angina equivalents, or variant angina) and reduced cerebral perfusion (for example, confusion, difficulty walking);
      3. The quality, location, radiation, and duration of the chest pain noted, along with factors that exacerbate the chest pain (for example, continued activity, deep breathing, etc.); and factors that relieve the chest pain (for example, rest, nitroglycerin, food, etc.);
      4. Any associated symptoms such as shortness of breath, diaphoresis, nausea, dizziness, lightheadedness, near syncope, or syncope;
      5. Intermittent claudication, swelling, and skin changes in the lower extremities; and
      6. Dates and results of relevant diagnostic procedures, such as electrocardiography, exercise-tolerance stress testing, angiography, echocardiography, Doppler tests, and any other imaging studies.
    2. Social history

      The CE provider will describe and discuss, as appropriate, any employment history relevant to the alleged condition(s) such as exposure to chemicals or irritants. Include pertinent findings about use of tobacco products, alcohol, and nonprescription drugs.

    3. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Lungs:

        1. Whether respiratory rate is labored or unlabored and diaphragmatic motion;
        2. Occurrence of cough, audible wheezing, pallor cyanosis, hoarseness, clubbing of fingers, chest wall deformity, any abnormal curvature of the spine; and
        3. Breath sounds (air exchange), whether there is prolongation of the exhalatory phase of respiration, and the presence or absence of adventitious sounds (such as rales or rhonchi).
      2. Heart and vascular:

        1. Presence of any lifts, heaves, or thrills;
        2. Heart size;
        3. Point of maximal impact of cardiac apex;
        4. Presence of any murmurs, rubs, or gallups;
        5. Presence and location of any bruits;
        6. Distention of neck veins;
        7. Presence, type, and extent of any peripheral edema and any associated skin discoloration or ulceration;
        8. Quality of peripheral pulses in extremities;
        9. Presence and quality of carotid pulses; and
        10. Presence of any abdominal pulsation or bruit.
      3. Electrocardiogram (ECG), exercise tolerance test (ETT), and Doppler test

        Obtain ECG, ETT, and Doppler test only after receiving proper authorization from the DDS.

        1. ECG: Perform as specified in section 4.00C of the cardiovascular listings (see https://www.ssa.gov/disability/professionals/bluebook/4.00-Cardiovascular-Adult.htm) and provide ECG tracings.
        2. ETT: Perform as specified in section 4.00C of the cardiovascular listings (see https://www.ssa.gov/disability/professionals/bluebook/4.00-Cardiovascular-Adult.htm).
        3. Doppler tests: Perform as specified in section 4.00C of the cardiovascular listings (see https://www.ssa.gov/disability/professionals/bluebook/4.00-Cardiovascular-Adult.htm).

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Digestive Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with digestive disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult digestive disorders

    The CE report guidelines for adult digestive disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to digestive disorders

    The CE provider will use the specific requirements below to complete the CE report for a digestive disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Fatigue, muscle weakness, sensory abnormalities, cognitive impairment, malaise, loss of appetite;
      2. Sleep disturbance and any other nocturnal symptoms;
      3. Pain, if present, and its location;
      4. Recent (involuntary) weight loss and the amount;
      5. Bowel and bladder patterns;
      6. Nausea; and
      7. Dates and results of relevant diagnostic procedures (such as diagnostic imaging, endoscopy, biopsy, aspiration of ascetic fluid, and clinical laboratory test).
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Presence of jaundice and pallor;
      2. Liver and spleen size;
      3. Muscle wasting;
      4. Presence of edema, ascites, and asterixis;
      5. Presence of any abdominal masses;
      6. Rectal bleeding (if the claimant allows the physician to observe his/her rectum);
      7. Evidence of perineal disease; and
      8. Superficial manifestations of liver disease, such as, spider angiomas, caput medusae, and/or altered venous flow on the abdomen.
    3. Laboratory tests or findings

      The CE provider will obtain laboratory testing only after receiving proper authorization from the DDS. Describe and discuss the results of such tests as appropriate:

      1. Serum creatinine;
      2. Serum total bilirubin;
      3. International normalized ratio (INR);
      4. Serum albumin; and
      5. Hemoglobin.

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Genitourinary Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with genitourinary disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult genitourinary disorders

    The CE report guidelines for adult genitourinary disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to genitourinary disorders

    The CE provider will use the specific requirements below to complete the CE report for a genitourinary disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Frequency of any renal dialysis, as well as the date of first dialysis;
      2. Fatigue;
      3. Dyspnea;
      4. Motor weakness and/or sensory abnormalities;
      5. Loss of appetite; and
      6. Dates and results of relevant diagnostic procedures, such as imaging studies, renal biopsy, and clinical laboratory tests.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Renal osteodystrophy;
      2. Ascites or anasarca;
      3. Pleural effusions;
      4. Type and location of any edema; and
      5. Any signs of cardiac involvement.

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Hematological Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with hematological disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report for adult hematological disorders

    The CE report guidelines for adult hematological disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to hematological disorders

    The CE provider will use the specific requirements below to complete the CE report for a hematological disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Dates and results of relevant diagnostic procedures such as complete blood count (CBC), mean corpuscular volume (MCV), platelets, reticulocyte count, serial hemoglobin, hemoglobin electrophoresis, blood smears, and bone marrow examination; and
      2. A detailed description of the following:

        1. Abnormal blood clotting;
        2. Pain crises;
        3. Infections; and
        4. Frequency of red blood cell (RBC) or other blood component transfusions or infusions.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Any apparent abnormalities such as pallor, jaundice, abnormal bruising, petechiae, ecchymoses, edema, fatigue level, or enlarged lymph nodes;
      2. Joint examination including swelling, tenderness, and range of motion;
      3. Abdominal examination including liver, spleen, or abnormal masses;
      4. General and focal neurologic examinations; and
      5. Mental status examination.

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Skin Disorders

Use the following are guidelines to provide minimum content for CE reports for adult claimants with skin disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult skin disorders

    The CE report guidelines for adult skin disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to skin disorders

    The CE provider will use the specific requirements below to complete the CE report for a skin disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Dates and results of relevant diagnostic procedures such as biopsy and genetic testing; and
      2. Treatment modalities, dates of treatments, and responses to treatments.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Contractures or type of skin lesion(s) and extent of the body affected;
      2. Duration of skin lesion(s);
      3. Joint function including range of motion of the affected joint(s);
      4. If there is involvement of the palmar and/or plantar surfaces, describe the effect on hand use and/or ambulation; and
      5. Optional with consent of the claimant: a digital photograph to document the severity of the skin lesion(s).

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Endocrine Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with endocrine disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report for adult endocrine disorders

    The CE report guidelines for adult endocrine disorders are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to endocrine disorders

    The CE provider will use the specific requirements below to complete the CE report for an endocrine disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Heat or cold intolerance;
      2. Sensory aberrations;
      3. Any vision loss;
      4. Convulsions, tetany, or episodes of alteration of consciousness;
      5. Bone pain or localization of pain;
      6. Abnormal bowel or urinary pattern; and
      7. Dates and results of relevant diagnostic procedures, such as CBC, liver enzymes, adrenal function, serum electrolytes, calcium and phosphorus, fasting blood glucose; glucose tolerance testing, Hb1AC, blood chemistries, T3, TSH, urinalysis, and relevant imaging studies.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Abnormal sweating, dry skin, or changes in color or texture of skin;
      2. Abnormal eye changes, such as exophthalmia, cataracts, visual field loss, extra ocular muscle movement, and fundus changes (retinitis proliferens);
      3. Abnormal masses of neck or abdomen;
      4. Peripheral neuropathy – sensory or motor;
      5. Presence of Chvostek or Trousseau signs; and
      6. Mental status examination.

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Neurological Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with neurological disorders. Each Disability Determination Services (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult neurological disorders

    The CE report guidelines for adult neurological disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to neurological disorders

    The CE provider will use the specific requirements below to complete the CE report for a neurological disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Cognitive impairment;
      2. Motor weakness;
      3. Sensory abnormalities;
      4. Problems with speech;
      5. Problems with swallowing;
      6. Problems with voiding and defecation;
      7. Complete description of seizures including type and severity, auras, behavior prior to seizure, diurnal or nocturnal, frequency per month during the past year, duration of episodes, postictal phenomena, and date of last three seizures;
      8. Cooperation with taking medication as prescribed and response to treatment;
      9. Blood levels, if available;
      10. Dates and results of relevant electrodiagnostic studies, such as EMG, NCV, evoked potentials, or EEG; and
      11. Headaches, including known triggers, frequency, length, and response to treatment.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Any apparent abnormalities in gait:

        1. Gait (including timed walking speed, when appropriate), or
        2. Need for any type of assistive device and the reason such device is needed.
      2. Mobility (including hand dominance) – ability to:

        1. Use the upper extremities effectively for gross and fine movements;
        2. Get up from a seated position and stand;
        3. Walk with and without assistance;
        4. Get on and off the examination table;
        5. Tandem walk; and
        6. Walk on heels and toes.
      3. Coordination – abnormal movements, especially tremors and incoordination
      4. Motor function:

        1. Strength – 0-5/5 (MRC scale) or dynamometer, when appropriate;
        2. Atrophy or flaccidity;
        3. Spasticity;
        4. Rigidity;
        5. Limitation of movement;
        6. Fatigability of extremities; and
        7. Reflexes – deep tendon and superficial.
      5. Myasthenia gravis or cases in which fatigue is alleged: Test for ability to fatigue the claimant by exercise (for example, ptosis develops after 1 minute of attempted up gaze or strength declines from 5/5 at rest to 2/5 after 10 minutes of exercise of a particular muscle).
      6. Cranial nerve functions:

        1. Visual acuity and confrontation visual fields;
        2. Pupillary response to light and accommodation;
        3. Examination of extraocular movements or presence of nystagmus;
        4. Facial sensation including corneal reflex and masseter strength and bulk;
        5. Facial muscle strength and symmetry;
        6. Hearing test; and
        7. Other functions, as appropriate, such as gag reflex, neck muscle strength, ability to detect odors, and tongue movement (strength or atrophy).
      7. Sensory function:

        1. Pattern – anatomic or non-anatomic; and
        2. Characteristics of any pain and relationship to underlying disorder.
      8. Mental status examination:

        1. Orientation;
        2. Memory;
        3. Calculation;
        4. Insight;
        5. General understanding;
        6. Fund of knowledge; and
        7. Mood and behavior during examination.
      9. Speech and language functioning:

        1. Intelligibility and fluency;
        2. Aphasia including ability to comprehend language or produce language either spoken or written;
        3. Dysarthria;
        4. Stuttering; and
        5. Involuntary vocalizations.

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Mental Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with mental disorders. Each Disability Determinations Service (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult mental disorders

    The CE report guidelines for adult mental disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Identification

    1. The CE provider will include the claimant’s name, date of birth, and/or claim number; and
    2. The CE provider will indicate that the claimant provided proof of identity by showing a valid and current government photo identification (for example, U.S. State-issued driver’s license, U.S. State-issued non-driver identity card, U.S. passport, U.S. military ID, or Student or school ID, etc.), or provide a physical description of the claimant to verify that the person being examined is the claimant, except if the claimant's medical source with a treating relationship is the CE provider.
  3. Medical history

    1. Longitudinal medical history

      1. The CE provider will cite and describe the medical records and any other documents reviewed during the course of the evaluation;
      2. The CE provider will identify the person(s) providing the oral medical history and an assessment of the validity and reliability of such information; and
      3. If the person providing the oral medical history is someone other than the claimant, the CE provider will indicate whether the person was interviewed separately or in the presence of the claimant.
    2. Current medical history

      1. The primary impairment(s) alleged as the reason for not working. This information must be in a narrative, rather than a “questionnaire” or “check-off” form, and pertinent descriptive statements by the claimant, should be recorded in the claimant’s own words. This description must include:

        1. History of the onset and progress of the disorder;
        2. The claimant’s statement of current symptom(s);
        3. Type and resultant effect of any treatment;
        4. Factors which increase the problem or impairment or that may provide relief; and
        5. The claimant’s typical daily activities and the claimant’s description of how their disorder(s) and or impairment(s) limit their ability to function.
      2. Information provided by the claimant, or other source. This report should provide a detailed description of the claimant’s:

        1. Ability to understand, remember, and apply information;
        2. Ability to interact with others;
        3. Ability to concentrate, persist, and maintain pace;
        4. Ability to adapt and manage oneself;
        5. Ability to function in personal, social, and occupational situations;
        6. Attempts to return to work and the results; and
        7. Daily activities.
    3. Past medical history

      1. Outpatient evaluations and treatment for mental and emotional problems, including:

        1. Names of medical sources providing treatment;
        2. Dates of treatment;
        3. Types of treatment (names and dosages of medications, if prescribed); and
        4. Response to treatment.
      2. Hospitalization for the disorder, including:

        1. Names of hospitals;
        2. Dates; and
        3. Treatment and response.
    4. Current medications

      The CE provider will list the name, dose, and frequency of medication(s), including both beneficial and adverse effects, and plans for continued drug administration, schedule, and extent of any therapy.

  4. Longitudinal account of the claimant's personal life

    The CE provider will describe and discuss, as appropriate:

    1. Relevant educational, medical, social, legal, military, marital, and occupational data; and any associated problems in adjustment;
    2. Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional conditions; and
    3. History, if any, of substance use or treatment in detoxification and rehabilitation centers.
  5. Mental status examination

    The CE provider will describe and discuss, as appropriate:

    1. Appearance, behavior, and speech (if not already described). For example, dress, grooming, and appearance of invalidism;
    2. Thought process. For example, loosening of associations;
    3. Thought content. For example, delusions;
    4. Perceptual abnormalities. For example, hallucinations;
    5. Mood and affect. For example, depression or mania;
    6. Sensorium and cognition. For example, orientation, concentration, remote memory, recall of new information, fund of information, and estimated intelligence;
    7. Judgment and insight;
    8. NOTE: The description of the claimant’s mental status must not be an enumeration of the symptoms reported by the claimant (or other source) in DI 22510.112 B.2. rather the description must be the examining source’s description of the above items.

    9. Further, the CE provider will describe and discuss general observations, as appropriate;
    10. How the claimant came to the examination;

      1. Alone or accompanied;
      2. Distance and mode of transportation; and
      3. If by automobile, who drove.
    11. Attitude and degree of cooperation;
    12. Posture and gait; and
    13. Involuntary movements.
  6. Diagnosis

    The report should include the American Psychiatric Association standard nomenclature as set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

  7. Prognosis

    The CE report should include prognosis and recommendations for treatment, if indicated. The report should also include recommendations for any other medical evaluation (for example, neurological, general physical), if indicated.

  8. Capability

    The report should include information about whether the claimant can manage his or her funds.

  9. Additional requirements for specific mental disorders

    1. Schizophrenia spectrum and other psychotic disorders

      If the claimant has alleged a disorder on the schizophrenia spectrum or other psychotic disorders the medical source must provide a detailed description of the following, as appropriate:

      1. Periods of residence in structured settings such as half-way houses and group homes;
      2. Frequency and duration of episodes of illness and periods of remission; and
      3. Side effects of medications.
    2. Neurocognitive disorders

      If the claimant has alleged a neurocognitive disorder, the medical source must provide a detailed description of the following, as appropriate:

      1. The etiology of the disorder and onset date (if known), the prognosis, and:

        1. Whether there is an acute or chronic process;
        2. Whether stable or progressive;
        3. Changes at various points in time; and
        4. Whether there has been a clinically significant decline in cognitive functioning and, if so, the basis for the conclusion that there has been a decline.
      2. The results of any psychological or neuropsychological testing that may have been performed that could serve to further document an organic process and its severity.
      3. Information regarding the results of any neurological evaluations.
    3. Intellectual disability

      The report of intellectual disability should include the following:

      1. Current documentation of IQ by a standardized test of general intelligence; Acceptable test instruments (for example, the Wechsler scales) are those that:

        1. Meet contemporary psychometric standards for validity, reliability, normative data, and scope of measurement;
        2. Are individually administered according to all pre-requisite testing conditions; and
        3. Have a mean of 100 and a standard deviation of 15.
      2. Summary of composite scores;

        For example, Full Scale IQ, Verbal Comprehension Index, Perceptual Reasoning Index together with the individual subtest scores.

      3. Interpretation of the obtained scores;

        The medical source should indicate whether the scores are representative of the claimant’s present level of intellectual functioning.

      4. Any factors that may have influenced the results, such as the claimant’s attitude and degree of cooperation, the presence of visual, hearing, or other physical problems, and recent prior exposure to the same or similar test; and
      5. Consistency of the obtained test results with the claimant’s education, vocational background, and social adjustment, especially in the area of personal self-sufficiency.
  10. Provide a medical opinion

    1. The CE provider will specify the nature and extent of the condition(s) or disorder(s);
    2. The CE provider will discuss any apparent discrepancies in the medical history or in the examination findings;
    3. The CE provider will specify any limitations in functioning that result for the condition(s) or disorder(s), including the claimant’s ability to:

      1. Understand, carry out, and remember instructions (both complex and one-two step);
      2. Sustain concentration and persist in work-related activity at a reasonable pace;
      3. Maintain effective social interaction on a consistent and independent basis, with supervisors, co-workers, and the public; and
      4. Deal with normal pressures in a competitive work setting.

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Cancer

Use the following guidelines to provide minimum content for CE reports for adult claimants with cancer. Each Disability Determinations Service (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for adult cancer

    The CE report guidelines for adult cancer in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to cancer

    The CE provider will use the specific requirements below to complete the CE report for cancer.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Fatigue, malaise, affected organ systems;
      2. Type of therapy received or planned;
      3. Response to therapy – surgical, radiation, and chemotherapy (for each cancer condition if more than one). If multimodal therapy, dates each completed/scheduled and performed by which physician;
      4. Effects of any post-therapeutic residuals;
      5. Planned treatment;
      6. Weight loss;
      7. Prognosis, if available; and
      8. Dates and results of relevant diagnostic procedures, such as biopsy or tissue pathologic examination and imaging studies.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Review any biopsy or tissue pathologic examination;
      2. Imaging studies; and
      3. Other body systems affected by adverse effects of treatment.

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Immune System Disorders

Use the following guidelines to provide minimum content for CE reports for adult claimants with immune system disorders. Each Disability Determinations Service (DDS) will notify medical sources of any additional requirements.

  1. General guidelines for CE report content for immune system disorders

    The CE report guidelines for immune system disorders in this section are in addition to the general CE report content guidelines. See General Consultative Examination and Report.

  2. Report content specific to immune system disorders

    The CE provider will use the specific requirements below to complete the CE report for an immune system disorder.

    1. Current medical history

      The CE provider will describe and discuss, as appropriate:

      1. Weight loss;
      2. Fever;
      3. Pain;
      4. Fatigue;
      5. Malaise;
      6. Degree of limitation in:

        1. Activities of daily living;
        2. Maintaining social functioning; and
        3. Completing tasks in a timely manner due to deficiencies in concentration, persistence, and pace; and
      7. Effects in other organ systems.
    2. Physical examination

      The CE provider will describe and discuss, as appropriate:

      1. Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive system, skin, etc.;
      2. Any apparent abnormalities such as gait or the need for any type of assistive device;

        1. If the claimant uses an assistive device(s), note the type of, and medical need for, the device.
        2. For lower extremity assistive devices, describe the claimant’s gait with and without use of the device.
      3. Ability to:

        1. Tandem walk;
        2. Walk on heels and toes;
        3. Bend;
        4. Squat;
        5. Get up from a seated position;
        6. Grasp or shake hands;
        7. Write; and
        8. Turn door handles.
      4. Extremities and peripheral joints:

        1. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;
        2. Effusion;
        3. Peri-articular swelling;
        4. Tenderness;
        5. Redness;
        6. Heat;
        7. Thickening;
        8. Structural deformities;
        9. Instability;
        10. Grip, pinch, and ability to fully close the fist (either by dynamometer or 0-5 scale);
        11. Extremity strength (either by dynamometer or 0-5 scale);
        12. Atrophy; and
        13. Ability to use, and effective use of, any orthoses.
      5. Spine:

        1. Distribution of pain, tenderness, sensory or motor loss; and
        2. Active range of spinal motion;

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