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IN THE QUESTIONNAIRE BELOW,
PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE.

ABOUT MYSELF A                    ABOUT MYSELF AND HOW TO CONTACT MEND HOW TO CONTACT ME

Name
Address
Apt / Ste
City
State
Zip
Day Phone
Night Phone
Email Address


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To receive a response sooner, please be sure to include your email address.

ABOUT MY CIRCUMSTANCES

Age I am years old
Gender Male      Female   
Level of Education Grade: 1-7     8-11     12-14     15-18
Work History I have worked at least 5 of the last 7 years   Yes    No
My Work Status I am currently working    Yes   No
Work Stop Date I stopped working on (mm/dd/yyyy)
Work Description Describe your job at the time your impairment(s) stopped you from working. Include any other work you have performed over the past fifteen years.
Medical Treatment I see my doctor(s) on a regular basis   Yes   No
Last Appointment The last appointment with my doctor(s) was (mm/dd/yyyy)
Medical Insurance I am currently insured     Yes    No
Number Of Doctors Total number of doctors I see at this time for my impairment(s)
Limitation 1 I use a prosthesis                                     Yes    No
Limitation 2 I have difficulty walking and standing   Yes    No
Limitation 3 I have difficulty sitting                        Yes    No
Limitation 4 I have difficulty using my hands          Yes    No
Impairments List each of your impairment(s) that have been medically diagnosed.
(For example: Arthritis, Degenerative Disc Disease, Emphysema, Lupus, etc.)

1.
 (If more than four impairments, continue listing
2.
   impairments in the fourth box, separating each
3.
   with a comma)
4.
Symptoms Describe the symptoms you experience for each impairment above, including your estimation of the severity and duration of the symptoms.
(For example: My degenerative disc disease causes pain (very severe and constant), fatigue (chronic and every day), and depression (mild, with medication, but everyday) and my emphysema causes shortness of breath (severe, constant).

A Brief History And Current Status Of My Disability

Describe the onset (cause) and circumstances related to your impairment(s) and the overall time frame in which they have occurred.

Why My Impairment Keeps Me From Working.

Describe the specific reasons why you believe your impairment(s) will or have stopped you from working and why they will continue to keep you from working.

ABOUT MY SSA DISABILITY BENEFIT CLAIM

(The following questions indicate whether or not you previously filed a disability benefits
claim directly with the Social Security Administration and the status of that claim)

I Have Never Applied     mm/dd/yyyy       (Use this date format in the fields below)
I Have Applied   Date of Application  
My Initial Application Was Denied   Date Initial Application Was Denied
I Filed For Reconsideration   Date of Request For Reconsideration
My Reconsideration Was Denied   Date Reconsideration Was Denied
I Filed For An ALJ Hearing   Date of Request For Hearing (ALJ)
My Hearing Is Not Yet Scheduled  
My Hearing Has Been Scheduled   Scheduled Date of Hearing
 
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