SSD Intake

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.

GCLID

Full Legal Name*

Email

DOB*

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)

GCLID

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

How many times you hospitalized in the past 2 years?

FOR EACH HOSPITALIZATION (limit your response to the previous 2 years)

GCLID

Name of Hospital

Address

Phone

Dates of Hospitalization

(approximate - month/year)

Reason for Hospitalization

Next Appointment Date

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

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

Body Part

Date of Testing

Doctor who ordered test

Psychological Testing

Body Part

Date of Testing

Doctor who ordered test

Other

Test Name

Body Part

Date of Testing

Doctor who ordered test

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

GCLID

Name of Medication

Reason

Prescribing Doctor

Side Effects

Total number of jobs in the last 5 years*

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

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

WORK HISTORY

Job Title

Type of Business

Approximate Start Date (MM/YYYY)

Approximate End Date (MM/YYYY)