Clinical findings (such as the results of physical or mental status examinations);
Laboratory findings (such as blood pressure, x-rays);
Treatment prescribed with response and prognosis;
A statement providing an opinion about what the claimant can still do despite his or her impairment(s), based on the medical source’s findings on the above factors. This statement should describe, but is not limited to, the individual’s ability to perform work-related activities such as …hearing…. For a child, the statement should describe his or her functional limitations in learning, …communicating.
SSA regulations also require that hearing tests “should be preceded by an otolaryngologic examination.” In contrast, the committee recommends that the otolaryngological examination should follow the audiological examination (but by no more than 6 months), because a physician cannot provide a competent report, including the six elements listed above, without recent audiometric data. The appropriate source for the otolaryngological examination is an otolaryngologist certified by the American Board of Otolaryngology. Otolaryngologists specialize in disorders of the ear, nose, throat, and related structures of the head and neck and have completed at least five years of residency training following receipt of the M.D. or D.O. (doctor of osteopathy) degree.
The elements of the medical history in an examination performed to provide medical evidence for SSA program eligibility are identical to those included in a routine medical examination. There are, however, some areas of emphasis worthy of mention.
Chief Complaint and Present Illness: The claimant’s chief otological complaint may not be hearing loss; it may be tinnitus, vertigo, otalgia, or otorrhea. For each significant otological symptom, but especially for hearing loss, the physician should inquire about:
The nature of the symptom—Are hearing difficulties noticed in one ear or both? For what types of sounds?
Chronology—Onset? Change over time? Fluctuation?
Exacerbating and/or ameliorating factors, such as background noise
Effects on activities of daily living—ordinary conversation, telephone use, work.