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Consultative Examinations are requested by Social Security disability examiners when it is determined that the information provided by a claimant’s own treating medical sources is inadequate for determining if the claimant is disabled. Most disability examiners will contact an individual’s treating physician for additional information or clarification, however there are cases in which this may be impossible, or there are times when a claimant has had very little medical treatment or all of their medical information is considered out dated for Social Security medical disability determinations. So what happens at a physical exam for Social Security disability or SSI? First of all, Social Security disability and SSI claimants go through the same disability process; consequently the same things happen during a physical exam for both disability programs. A complete consultative physical exam would involve all of the elements of a routine physical examination. For instance, your blood pressure, heart rate, weight, and other routine facets of a standard physical examination would be checked. In addition to the examination, the consultative physician would have to complete a written report that would involve the following elements: The report would include the claimant's main medical complaint, a detailed synopsis of the individual's major complaint or complaints, a report of the positive and negative findings based upon the history, exam, and laboratory findings that were found during the course of the examination, as well as a diagnosis and prognosis for the claimant. In addition to the more routine things included in the consultative report, the consultative physician will make a statement with regard to what a claimant is capable of doing in spite of their impairment. The consultative physician will give an a opinion as to the claimant's ability to perform work related activities such as lifting, carrying, standing, walking, handling things, hearing, speaking, etc. You may be wondering why Social Security has the consultative exam physician write a statement as to the claimant’s ability to perform activities related to work. Remember, Social Security and Supplemental Security Income disability is based upon an individual's residual functional capacity (what an individual is able to do in spite of the limitations caused by their medical problems) rather than specific medical impairments. If an individual's residual functional capacity is so limited that it precludes work activities, an individual may be approved for disability benefits. 
Social Security Disability and SSI Disability Information
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