SOCIAL SECURITY DISABILITY INTAKE FORM

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GENERAL INFORMATION - Step 1 of 6

Thank you for allowing us to represent you in your claim for disability benefits. In order for us to efficiently process your application or appeal, complete this questionnaire about your medical treatment and work history. Most importantly, this information ensures that all medical records are obtained for your claim.

FULL LEGAL NAME *

First

Middle

Last

EMAIL *

DOB *

ADDRESS *

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HOW MANY DOCTORS HAVE YOU SEEN IN THE PAST 2 YEARS? *

FOR EACH DOCTOR OR MEDICAL OFFICE (LIMIT YOUR RESPONSE TO THE PREVIOUS 2 YEARS)

DOCTOR

NAME OF DOCTOR OR MEDICAL OFFICE *

ADDRESS

PHONE

FIRST DATE OF TREATMENT

(approximate - month/year)

MOST RECENT DATE OF TREATMENT *

(approximate - month/year)

NEXT APPOINTMENT DATE

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HOW MANY TIMES HAVE YOU BEEN HOSPITALIZED IN THE PAST 2 YEARS?

FOR EACH HOSPITALIZATION (LIMIT YOUR RESPONSE TO THE PREVIOUS 2 YEARS)

HOSPITAL VISIT

NAME OF HOSPITAL

ADDRESS

PHONE

DATES OF HOSPITALIZATION

(approximate - month/year)

REASON FOR HOSPITALIZATION

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Please list all testing you have received/completed in the past two years and specify part of the body, if applicable. This includes mri, ct scans, x-rays, nerve testing, blood work and psychology testing.

MRI/CT SCAN

BODY PART

DATE OF TESTING

DOCTOR WHO ORDERED TEST

MANY BODY LAST

X-RAY

BODY PART

DATE OF TESTING

DOCTOR WHO ORDERED TEST

EMG/NERVE TESTING

BODY PART

DATE OF TESTING

DOCTOR WHO ORDERED TEST

BLOOD WORK

DATE OF TESTING

DOCTOR WHO ORDERED TEST

PSYCHOLOGICAL TESTING

DATE OF TESTING

DOCTOR WHO ORDERED TEST

Other

Test Name

BODY PART

DATE OF TESTING

DOCTOR WHO ORDERED TEST

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HOW MANY MEDICATIONS ARE YOU CURRENTLY TAKING?

PLEASE LIST ALL CURRENT MEDICATIONS ALONG WITH THE DOCTOR WHO PRESCRIBED THE MEDICATION, REASON FOR MEDICATION AND ANY SIDE EFFECTS

CURRENT MEDICATIONS

NAME OF MEDICATION

REASON

PRESCRIBING DOCTOR

SIDE EFFECTS YOU PERSONALLY EXPERIENCE

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TOTAL NUMBER OF JOBS IN THE LAST 5 YEARS *

Please enter "0" if you have not worked in the last 5 years

WORK HISTORY

For each job please complete the following for the 5 most recent jobs

JOB TITLE

TYPE OF BUSINESS

APPROXIMATE START DATE (MM/YYYY)

APPROXIMATE END DATE (MM/YYYY)

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