The evidence must document the individual's medical condition and indicate how his impairment affects his ability to engage in substantial gainful activity.
The medical evidence must show that the individual has an impairment which meets or equals the listing of impairments established by the Social Security regulations for determining disability. See Appendix A.
The evidence must also document the severity of the impairment during the time the individual says he is disabled. The medical evidence must contain the following:
A history of the impairment.
Reports of clinical and laboratory findings which support the diagnosis and show the physical or mental changes which have occurred.
The factual data which is the basis for the diagnosis and prognosis.
A medical assessment describing the individual’s ability to do work related activities such as sitting, standing, moving about, lifting, carrying, handling objects, hearing, speaking, and traveling. If the individual has a mental impairment, the assessment should describe his ability to reason or make occupational, personal, or social adjustments.
The evidence must also document the individual's ability to engage in substantial gainful activity. Factors such as age, education, work experience, and vocational skills affect ability to work.
For an accurate evaluation of vocational factors, the file must contain the following information:
Age.
Education and training.
Work experience - the specific duties, skills, and physical and mental demands of the individual's past jobs.
Efforts to work.
Daily activities before and after the date the individual said he became disabled; and
Ability to speak and understand English.
Reissued September 20, 2006, replacing July 26, 2005; reviewed March 16, 2012