SOCIAL SECURITY DISABILITY/SSI DATA SHEET

Date:_________________                                          Referred By:___________________

Name:______________________                              Birth Date:____________________

Street Address:___________________________________________________________

Telephone Num.:_(Home)_______________ _(Work)_____________________

Citizenship:____________________________Education:________________________

Date of first application for SSD and\or SSI benefits:_____________________________

Date in your application you stated you become unable to work:____________________

List all health conditions and approximate date each condition first began to bother you.

Condition:                                                                     Date of first Symptoms:

__________________________________                ______________________________

__________________________________                ______________________________

__________________________________                ______________________________

__________________________________                ______________________________

__________________________________                ______________________________

Date and reason you stopped working:_________________________________________

________________________________________________________________________

Why you can no longer work:________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please list all physicians, clinics, hospitals, etc. from witch you have sought treatment for your condition and state whether you are currently being treated for same.

Physician\Facility                                  Address\Telephone                   Currently Treating

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________                                             

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________

____________________                    ___________________                      Yes      No

                                                            ___________________