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Full name
Maiden name
Other names used
E-mail Address
Phone number
Business phone
Cell phone
Address
City
State
Zip
Please describe all of your injuries, illnesses, symptoms, and disabilities, whether physical,
mental, or emotional.
How do your medical problems limit your daily activities?
Are you able to work?
Are/were you self-employed?
What is your age?
What is the last grade you completed in school?
Do you have a high school diploma or its equivalent?
Do you attend a vocational school or program?
If so, what did you study and did you earn any certifications or licenses?
Did you attend college?
If so, what did you study and did you earn any degrees?
Please describe any graduate study or advanced or professional degrees.
Do you possess any vocational or professional licenses?
Approximately how long have you been in the workforce? (years)
Describe briefly the types of work you have performed.
If you are able to work, how many hours can you work per week?
Have you filed for disability benefits for the medical problem/s described above?
Have you been turned down for benefit payments based on the medical problem/s described above?
Have you appealed a Social Security decision that denied you benefits for the medical problem/s
described above?
Other information or concerns?
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