Treating Physicians - Social Security Disability Attorney ...



Social Security Disability Questionnaire Date___________________Name ___________________ ___________________ ___________________FirstMiddleLastAddress _____________________________________________________________________________Phone Number ______________________Alternate ______________________Email Address ____________________________________Date of Onset of Disability____________Last Date of Work _______________Date of Birth ___________________City of Birth ___________________Social Security Number ___________________ Mother’s Maiden Name ___________________Are you a U.S. Citizen? □ Yes □ NoIf “no,” what is your status? ___________________________________________________________Spouse’s Name ________________________ ___________________ FirstLastDate of Marriage ___________________ Is your spouse receiving SSD or SSI? □ Yes □ NoSpouse’s Date of Birth ___________________Dependent Child’s Name ___________________Date of Birth ___________________Dependent Child’s Name ___________________Date of Birth ___________________Are any of your children receiving SSI?□ Yes □ NoDo you have a child age 18 or older that is disabled? □ Yes □ NoDo you have any prior applications for Social Security? □ Yes □ NoIf “yes,” date of prior application(s) and/or decision(s) ____________________________________Have you ever been overpaid by Social Security? □ Yes □ NoHighest grade completed and when ___________________ Special Education _________________Do you have a non-doctor friend or family member that knows the details of your medical conditions? □ Yes □ NoIf “yes,” please give their name, address, and phone number___________________________________________________________________________________________________________________________Have you had formal vocational training? □ Yes □ NoIf “yes,” where and when? _____________________________________________________________Do you have Military Service experience? □ Yes □ NoIf “yes,” dates served ___________________________ Branch of service ______________________Since you last worked, have you applied for or received any of the following benefits:Unemployment Compensation□ Yes □ NoWorkers’ Compensation□ Yes □ NoAutomobile no-fault benefits□ Yes □ NoShort term or long term disability benefits□ Yes □ NoVeteran’s Benefits□ Yes □ NoState Disability Assistance through DHS□ Yes □ NoUnused vacation/personal time/sick pay□ Yes □ NoRetirement Benefits through Social Security□ Yes □ NoPension or Retirement Benefits from any source□ Yes □ NoIf “yes” to any of the above benefits, please specify the date benefits began/ended and amount received, or bring a copy of any documentation reflecting this information._____________________________________________________________________________________Are you currently receiving money from any source other than what is listed above? □ Yes □ NoIf “yes,” please detail the amount and the source of the money (i.e., child support, alimony)_____________________________________________________________________________________Do you have a Disability Rating through the Veteran’s Administration? □ Yes □ NoIf “yes,” please provide a copy of your Disability Rating/Award Letter from the VA.Do you have a child support obligation through the Friend of the Court? □ Yes □ NoIf “yes,” please provide the amount of the arrearage(s) ____________________________________Do you have any IRS liens (an item of property given to secure the payment of a debt), state tax liens, or other governmental liens of any nature? □ Yes □ NoIf “yes,” please provide the nature of the lien, amount of the lien, and any enforcement proceedings that have been initiated ________________________________________________________________________________________________________________________________________List the injuries/conditions that limit your ability to work._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Treating PhysiciansDr. ___________________________Address ________________________________________________________________________Telephone ___________________________First Date Seen ___________________ Last Date Seen __________________ Next Appointment, if scheduled ___________________________Treatments_________________________________________Tests given/ordered (MRI, X-ray, EKG, etc) Please add in the body part tested and when the test happened_____________________________________________________________________________________________________________________Dr. ___________________________Address ________________________________________________________________________Telephone ___________________________First Date Seen ___________________ Last Date Seen __________________ Next Appointment, if scheduled ___________________________Treatments_________________________________________Tests given/ordered (MRI, X-ray, EKG, etc) Please add in the body part tested and when the test happened_____________________________________________________________________________________________________________________Dr. ___________________________Address ________________________________________________________________________Telephone ___________________________First Date Seen ___________________ Last Date Seen __________________ Next Appointment, if scheduled ___________________________Treatments_________________________________________Tests given/ordered (MRI, X-ray, EKG, etc) Please add in the body part tested and when the test happened_____________________________________________________________________________________________________________________(please add any other doctors on the back of this page)Have any of your doctors imposed any written restrictions? □ Yes □ NoIf “yes,” please specify which doctor and what restrictions were given ___________________________________________________________________________________________________________Please list all Hospitals/Medical Centers/Psychiatric Hospitals where you have been seen and the dates__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MedicationsName/DosageWho PrescribedReasonSide EffectsHave you ever been treated for alcohol and/or drug (prescription or non-prescription) dependence? □ Yes □ NoDo you have a medical marijuana card? □ Yes □ NoHave you ever been incarcerated for any length of time since your disability began? □ Yes □ NoIf “yes,” please provide details with dates of incarceration ______________________________________________________________________________________________________________________Have you ever been convicted of a crime? □ Yes □ NoIf “yes,” please specify the crime and date(s) of conviction ______________________________________________________________________________________________________________________What doctor would be supportive of your claim? _________________________________________ ................
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