You should. If not, the Service will ask for it in a Request for Evidence. You are better off filing it with everything.
You may want to consider speaking with an attorney to file your case, as this is a very basic question.
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Submit it together with the I-485 otherwise you will receive a Request For Evidence (RFE) that may cause delays. The I-693 medical exam should be performed by a civil surgeon listed on the USCIS.gov site and should be in a sealed envelope. I would urge you to consult with an experienced immigration lawyer to discuss other documents you should be submitting as well.
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You should submit it together. THis is a pretty basic question and clearly stated in the instructions. The more important question is whether you should be going through the process without a lawyer? What if you are missing something very important that you do not even know to consider? It happens to many people and it is much harder to correct later than to get it right the first time.