A complete medical report should include medical history, clinical and laboratory findings, diagnosis, prognosis, and a statement about what the individual can still do despite his or her impairments. However, we will accept and evaluate any medical evidence, even if it is not a complete report. The medical history should be thorough, and discuss the onset and duration of the individual's illness. Establishing the correct disability onset date is important because it may affect when cash benefits and Medicare coverage begin. A medical report should also describe the standard positive and negative findings of a thorough physical or mental examination.
Progress notes that document findings are also helpful.
Copies of laboratory findings, including HIV testing, should also be included, if available. A diagnosis and prognosis consistent with the medical data should be included. A diagnosis of HIV infection that is not supported by laboratory test results should be explained. The following outline describes the type of information that is particularly useful to us. Low energy, fatigue, weakness 2.