Skip to main content

Elements of a Consultative Examination (CE) Report for a Disability Based on a Mental Disorder

The CE report should show not only the individual’s symptoms, laboratory findings (psychological test results), and diagnosis but also the effect of the mental disorder on the individual’s ability to function in personal, social, and occupational situations.

Elements of a CE Report

General observations

The CE report should include general observations of:
  • How the individual came to the examination:
    • Alone or accompanied
    • Distance and mode of transportation
    • If by automobile, who drove
  • General appearance
    • Dress
    • Grooming
    • Appearance of invalidism
  • Attitude and degree of cooperation
  • Posture and gait
  • Involuntary movements


The consultative examiner should identify the person providing the history (usually the claimant) and should provide an estimate of the reliability of the history.

Chief Complaint

This usually will consist of the individual’s allegations concerning any mental or physical problems.

History of Present Illness

This should include a detailed chronological account of the onset and progression of the individual’s current mental/emotional condition with special reference to:
  • Date and circumstances of onset of the condition
  • Date the individual reported that the condition began to interfere with work, and how it interfered
  • Date the individual reported inability to work because of the condition, and the circumstances
  • Attempts to return to work and the results
  • Outpatient evaluations and treatment for mental and emotional problems, including:
  • Names of treating sources
  • Dates of treatment
  • Types of treatment (names and dosages of medications, if prescribed)
  • Response to treatment
  • Hospitalizations for mental disorders, including:
    • Names of hospitals
    • Dates
    • Treatment and response
  • Information concerning the individual’s:
    • Activities of daily living
    • Social functioning
    • Ability to complete tasks in timely fashion and appropriately
    • Episodes of decompensation and their resulting effects

Past History

This should include a longitudinal account of the individual’s personal life, including:
  • Relevant educational, medical, social, legal, military, marital, and occupational data and any associated problems in adjustment
  • Details (dates, places, etc.) of any past history of outpatient treatment and hospitalizations for mental/emotional problems
  • History, if any, of substance use and/or treatment in detoxification and rehabilitation centers

Mental Status

The individual case facts will determine the specific areas of mental status that need to be emphasized during the examination, but generally the report should include a detailed description of the individual’s:
  • Appearance, behavior, and speech (if not already described)
  • Thought process (e.g., loosening of associations)
  • Thought content (e.g., delusions)
  • Perceptual abnormalities (e.g., hallucinations)
  • Mood and affect (e.g., depression, mania)
  • Sensorium and cognition (e.g., orientation, recall, memory, concentration, fund of information, and intelligence)
  • Judgment and insight


This should include the American Psychiatric Association standard nomenclature as set forth in the current Diagnostic and Statistical Manual of Mental Disorders, or DSM-V.


Prognosis and recommendations for treatment, if indicated, should be provided. Recommendations for any other medical evaluation (e.g., neurological, general physical) should also be given, if indicated.

Capability Development

Develop capability in every case (initial, reconsideration, continuing disability review when a CE for a mental disorder is being purchased). (Capability refers to an individual’s ability to manage his or her funds.)