Social Security Assessment - Utah Disability P C

Name

How old are you?

Are you currently working?

What is the last date you worked?

Have you applied for Social Security Disability previously?

Out of the last 10 years, have you worked at least 5 of those years full time?

Have you looked at your earnings report from Social Security?

What medical conditions prevent you from working?

Are you currently seeing a Physician for your conditions?

How long have you been seeing this doctor?

Did this doctor encourage you to apply for disability?

Could you work at a different occupation? What would that job be?

What is your current occupation?

What city do you live in?

What is your phone number?

Do you have an email address?

Education

Special education resource High School or GED Some college, no degree 4+ years college

Other Information

Honorable Discharge Less than Honorable Discharge I have a VA rating for disability

Frequency of Medical Treatment

Currently being treated by a Primary Care Physician who is a PA Currently being treated by a Primary Care Physician who is an MD Currently being treated by a Specialist No treatment within one year No treatment in the last three years

Is your Doctor cooperative in helping you with information for a claim?

Yes No

Other important facts

Obesity with a BMI greater than 40 Use of a cane/walker/wheelchair History of a transplant Any cancer diagnosed within the last year?

Support

Do you have family support to help you emotionally? Do you have a spouse who is providing income/insurance? Did you need help from a family member to do this assessment? Are you able to read? Is English a second language for you?