Social Security intake

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SSN*

DOB*

Age*

Phone(H)*

Phone(C)*

Place of Birth*

Mother's Maiden Name*

Referred By*

Case History*

Cause of Disability*

Does Your Currently Need to Be Appealed*

Yes
No

If yes, what is the date on your most recent turn down letter

Education

Last Grade Completed*

Special Education*

Yes
No

Employment History

Employer 1*

First Day Worked*

Last Day Worked*

Description of Duties*

Reason for Leaving*

Employer 2*

First Day Worked*

Last Day Worked*

Description of Duties*

Reason for Leaving*

Personal Information

Height*

Weight*

Are you married*

Yes
No

Do you currently have health insurance*

Yes
No

If no, how are paying for continued medical care

Do you smoke*

Yes
No

If yes, please list frequency and amount

Do you drink*

Yes
No

If yes, please list frequency and amount

Have you used illegal drugs in the last fifteen years*

Yes
No

If yes, please list type and frequency of use

Have you used prescription drugs not prescribed to you in the last fifteen years*

Yes
No

If yes, please list type and frequency of use

Have you been incarcerated at any point in the last fifteen years*

Yes
No

If yes, please list reason for, length, and place of incarceration

Medical Information

Medical Information*

Doctor's Name	Doctor's Specialty	Address	Telephone	Are you currently receiving care from this Doctor Yes No	If Yes, how often do you see this Doctor	Which of your conditions does this Doctor treat

Hospitalization

Have you been hospitalized for any condition*

Yes
No

If yes, please list the hospital's contact information, approximate dates you were there, and the reason for your hospitalization

Name of hospital*

Name of hospital	Address	Dates	Reason for hospitalization

MedicationsPlease list all medications you are currently taking

*

Name	Dosage	Frequency