Social Security Questionnaire:

Your Information:

Name (first middle last)  

Date of Birth  

Address:  

Name of Employer:  

City:  

Employer Address:  

State:  

City:  

Zip:  

State:  

Email:  

Zip:  

Home Telephone:  

Spouse's full name:  

Cell Telephone:  

Spouse's Date of Birth:  


Children:

Name

Date of Birth

1.

2.

3.

4.

5.

6.

Please list any additional children in the comments secion


Education:

What was the last grade completed?  

What grades did you receive in school?  

Do you have any college education?  

Do you have any trade school education?  

 

Do you have any military training?  

 

Do you have any problems reading a newspaper?  

 

Do you have any problems writing a letter?  

 

Do you have any problems with doing math?  

 

Work Experience in Last 15 Years:
 

Employer Name

Dates

Position

Duties

1.

2.

3.

4.

5.

6.

Please list any additional employers in the comments secion


Accident or Onset of Disability:

When:  

Where:  

Please explain what happened:

Medical Treatment:
 

Name of Doctor
(First & Last)

Address

Telephone

Date(s)

Medical Problem

Which Tests Were Run?

1.  
2.  
3.  
4.  
5.  
6.  

 

Hospital

Address

Telephone

Date(s)

Medical Problem

Which Tests Were Run?

1.  
2.  
3.  
4.  
5.  
6.  

List all pain, disabilities, medical problems and injuries:

Description

How Often

When Start

Effect of Treatment


What effect does disability have on household chores?  

What effect does disability have on outdoor chores?  

What effect does disability have on hobbies/physical activities?

What effect does disability have on ability to do past work?  


Medication:

Name of Drug

Dosage

Prescribing Doctor

For what medical problem?


Has your medical problems gotten better, worse or the same since the initial injury?  

What effect does disability have on outdoor chores?  


Describe the reason for your visit:

List of documents that should be brought in for the initial office conference:

* All Letters from Social Security Administration
* All medical reports from hospitals and doctors
* All decisions from Social Security Administration






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