The CE provider will describe and discuss, as appropriate:

a. Weight loss;

b. Fever;

c. Pain;

d. Fatigue;

e. Malaise;

f. Degree of limitation in:

1. Activities of daily living;

2. Maintaining social functioning; and

3. Completing tasks in a timely manner due to deficiencies in concentration, persistence, and pace; and

g. Effects in other organ systems.

The CE provider will describe and discuss, as appropriate:

a. Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive system, skin, etc.;

b. Any apparent abnormalities such as gait or the need for any type of assistive device;

1. If the claimant uses an assistive device(s), note the type of, and medical need for, the device.

2. For lower extremity assistive devices, describe the claimant’s gait with and without use of the device.

b. Ability to:

1. Tandem walk;

2. Walk on heels and toes;

3. Bend;

4. Squat;

5. Get up from a seated position;

6. Grasp or shake hands;

7. Write; and

8. Turn door handles.

c. Extremities and peripheral joints:

1. If active range of motion is abnormal, describe passive range of motion and how active range of motion differs from passive range of motion;

2. Effusion;

3. Periarticular swelling;

4. Tenderness;

5. Redness;

6. Heat;

7. Thickening;

8. Structural deformities;

9. Instability;

10. Grip, pinch, and ability to fully close the fist (either by dynamometer or 0-5 scale);

11. Extremity strength (either by dynamometer or 0-5 scale);

12. Atrophy; and

13. Ability to use, and effective use of, any orthoses.

d. Spine:

1. Distribution of pain, tenderness, sensory or motor loss; and

2. Active range of spinal motion;