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Name
Address
City ST Zip
Phone
E-mail
Date of Birth

Education completed
Other Education
Description of past job
Job skills learned
How long held?
Reason for leaving
Date last worked
Any work since last job, even part time? Yes No Dates employed Earnings per month Type of work

Description of medical problems and how they affect work

Have you (or client) worked at least 5 of the last 10 years in jobs where taxes were paid? Yes No

Status of Social Security claim (select and complete all that apply)

Haven't applied yet

Applied but no decision Date applied

Received first denial? Date
Appealed? Date

Received second denial? Date
    Appealed? Date
    Hearing scheduled? Date Location
    Claim denied after hearing - Date
         Appealed? Date
    Appeals Council denial? Date
    Federal court suit filed? Date

Any prior applications for SSD? Yes No
Dates Actions taken

Private Disability Insurance
Any private insurance for disability? Yes    No
    Provided by employer or self obtained?
Name of disability insurance company
Currently receiving benefits? Yes    No
    Monthly amount? Date started receiving

Medical treatment (Pick all that apply)

Workers Compensation Benefits (select one)

Currently receiving benefits Amount weekly
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Case pending Where

Case closed Settlement amount Date

Worker's Comp Attorney name (if applicable)

Other Legal Action
Personal injury case pending? Yes No
Attorney

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