SSD Intake "*" indicates required fields Step 1 of 6 - GENERAL INFORMATION 16% 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 DOB* MM slash DD slash YYYY 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)Name of doctor or medical office* AddressPhoneFirst Date of Treatment (approximate - month/year) Most Recent Date of Treatment* (approximate - month/year) Next Appointment Date Add Another DoctorRemove Doctor How many times you hospitalized in the past 2 years? FOR EACH HOSPITALIZATION (limit your response to the previous 2 years)Name of Hospital AddressPhoneDates of Hospitalization (approximate - month/year)Reason for Hospitalization Next Appointment Date Add Another Hospital VisitRemove Hospital Visit 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 SCANBody Part Date of Testing Doctor who ordered test Add MRI/CT SCANRemove MRI/CT SCAN X-rayBody Part Date of Testing Doctor who ordered test Add X-rayRemove X-ray EMG/Nerve TestingBody Part Date of Testing Doctor who ordered test Add EMG/Nerve TestingRemove EMG/Nerve Testing Blood WorkBody Part Date of Testing Doctor who ordered test Add Blood WorkRemove Blood Work Psychological TestingBody Part Date of Testing Doctor who ordered test Add Psychological TestingRemove Psychological Testing OtherTest Name Body Part Date of Testing Doctor who ordered test Add OtherRemove Other 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 MEDICATIONSName of Medication Reason Prescribing Doctor Side EffectsAdd MedicationRemove Medication Total number of jobs in the last 15 years*Please enter "0" if you have not worked in the last 15 yearsFor each job please complete the following for the 5 most recent jobs WORK HISTORYJob Title Type of Business Approximate Start Date (MM/YYYY) Approximate End Date (MM/YYYY) AddRemove
