The CE provider will describe and discuss, as appropriate:

a. Character and severity of visual loss; and

b. Dates and results of relevant diagnostic procedures, such as imaging studies, visual acuity testing, and visual field testing.

The CE provider will describe and discuss, as appropriate:

a. 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.

b. Examination of pupils, external examination, and extraocular motions;

c. 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.

d. Intraocular pressure for each eye;

e. Slit lamp examination: include detailed description of the cornea and lens;

f. Fundus examination: include detailed description of the discs, vessels, maculae, and peripheral retina; and

g. 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.

The CE provider will describe and discuss, as appropriate:

a. Character and severity of hearing loss; and

b. Dates and results of relevant diagnostic procedures, such as audiometry, typanography, and MRI.

The CE provider will describe and discuss, as appropriate:

a. Examination of the ears, nose, and throat;

b. An otologic examination;

1. The external ears (pinnae and external ear canals) and the tympanic membranes; and

2. Any middle ear abnormalities.

c. 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.

d. 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.

e. 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.

The CE provider will describe and discuss, as appropriate:

a. Episodes of vertigo, including frequency, severity, and duration of the attacks;

b. Nausea and vomiting;

c. Ataxia;

d. Tinnitus;

e. Progressive hearing loss; and

f. Dates and results of relevant diagnostic procedures such as x-rays, CT scan, MRI, or radio-nuclear bone scan.

The CE provider will describe and discuss, as appropriate:

a. Examination of the ears, nose, and throat;

b. An otologic examination;

1. Describe the external ears (pinnae and external ear canals) and the tympanic membranes; and

2. Assess any middle ear abnormalities.

c. Report the presence of absence of nystagmus, Romberg results, and cerebellar signs;

d. The results of any caloric and other vestibular tests; and

e. Pure tone audiometry showing progressive hearing loss with special examinations such as Bekesy audiometry.

The CE provider will describe and discuss, as appropriate:

a. Duration, onset, and cause of the speech sound disorder(s), if known;

b. Dates and results of any relevant diagnostic procedures or testing; and

c. Treatment modalities, dates of treatments, and responses to treatments.

The CE provider will describe and discuss, as appropriate:

a. The claimant's ability to produce and sustain speech;

b. The use of, or need for, any voice modulation or amplification devices;

c. The claimant's speech articulation and volume for sustained speech; and

d. The presence of abnormalities such as aphasia, dysarthia, stuttering, or involuntary vocalizations.