Social Security Initial Interview Form

Background Information

First name: MI: Last name:

Maiden name, former names and/or aliases:

Address:

City: State: Zip:

Home Phone: Work Phone:

*Email Address:   

Other means of contact:

Marital status: Single Married Divorced

Spouse's full name, if any:

Number of children living at home under age 18:

Date of Birth: / /

Current age: Current Height: Current Weight:

Nationality:

Military backround (if any) (bring in your DD214):


Social Security Claim Information and Status

Have you EVER previously applied for Social Security Benefits? Yes No

If so, please state date of filing and check the type of benefits applied for:

Date: / / Disability: SSI: Both:

Date: / / Disability: SSI: Both:

Have you been turned down on your initial application? Yes No Date: / /

Have you applied for reconsideration of the denial? Yes No Date: / /

Have you requested a hearing before an ALJ? Yes No Date: / /

Have your Social Security Benefits been terminated? Yes No Date: / /

In your initial application, what date did you give as the onset date of your total disability? Date: / /


Disability Information and Treatment

Describe in detail the disabilities that you are claiming since the dates of your alleged onset date:

Medical treatment of disabilities (Please list names and addresses of doctors, therapists AND hospitals who have or are now treating you for the above disabilities):

1. Name: Address:

2. Name: Address:

3. Name: Address:

4. Name: Address:

5. Name: Address:

6. Name: Address:

7. Name: Address:

8. Name: Address:

Current medications (Include any prescription and/or over-the-counter drugs now taken):

1. Name of drug: Dosage: Doctor prescribing:

2. Name of drug: Dosage: Doctor prescribing:

3. Name of drug: Dosage: Doctor prescribing:

4. Name of drug: Dosage: Doctor prescribing:

5. Name of drug: Dosage: Doctor prescribing:


Vocational/Past Employment Information

Have you worked at all (W-2 earnings) since the onset of your disability? Yes No

Have you worked at all since you filed for Social Security Benefits? Yes No

If yes, please state (If no, please fill out the information below for your most recent employer prior to your date of alleged onset):

Employer:

Address:

City: State: Zip:

Phone:

Position:

Date employment began: / / Date last worked: / /

Job responsibilities/duties:


Education and Training

Please state the school names, dates attended, location and last grade completed.

Elementary School(s)

Junior High/High School(s)

Date graduated: / /

GED: Yes No Date: / / Location:

Vocational, military and/or further training (in any):

Have you ever applied for or received V.A. benefits or other long term disability benefits? Yes No

If so, please state the nature of such benefits:


Employment History (In reverse order)

Please verify with old tax returns or W-2s, if possible:

Employer: Start date: / / End date: / / Rate of pay:

Job title and duties/responsibilities:

Employer: Start date: / / End date: / / Rate of pay:

Job title and duties/responsibilities:

Employer: Start date: / / End date: / / Rate of pay:

Job title and duties/responsibilities:

Employer: Start date: / / End date: / / Rate of pay:

Job title and duties/responsibilities:

Employer: Start date: / / End date: / / Rate of pay:

Job title and duties/responsibilities:


Additional Information

To aid the location of improtant records

Place of birth:

Former/Past Residences (in reverse order):

1.

2.

3.

4.

5.


Current Sources of Income

Welfare, food stamps, V.A., private disability...


Permanent Injuries

Have you ever had a permanent injury involving:

Eyes: Yes No Explanation/Comments:

Nose/Sinus: Yes No Explanation/Comments:

Hearing: Yes No Explanation/Comments:

Mouth/Jaw/Speech: Yes No Explanation/Comments:

Head/Brain: Yes No Explanation/Comments:

Neck: Yes No Explanation/Comments:

Shoulders: Yes No Explanation/Comments:

Left/Right Arms-Elbows-Shoulders: Yes No Explanation/Comments:

Hands/Wrists: Yes No Explanation/Comments:

Lumbar Spine/Back: Yes No Explanation/Comments:

Left/Right Hips: Yes No Explanation/Comments:

Left/Right Legs: Yes No Explanation/Comments:

Left/Right Knees: Yes No Explanation/Comments:

Ankles/Feet: Yes No Explanation/Comments:

Kidneys/Bladder: Yes No Explanation/Comments:

Colon/Intestinal/Stomach: Yes No Explanation/Comments:

Liver/Pancreas: Yes No Explanation/Comments:

Asthma/Lungs: Yes No Explanation/Comments:

Diabetes: Yes No Explanation/Comments:

Obesity: Yes No Explanation/Comments:

Allergies: Yes No Explanation/Comments:

Skin Disorders: Yes No Explanation/Comments:

Heart Disease/Rheumatic Fever: Yes No Explanation/Comments:

High Blood Pressure/Stoke: Yes No Explanation/Comments:

Cancer: Yes No Explanation/Comments:

Other Disabling Disease: Yes No Explanation/Comments:

Alcohol Abuse: Yes No Explanation/Comments:

Drug/Substance Abuse: Yes No Explanation/Comments:

Mental Problems: Yes No Explanation/Comments:


Criminal History

Do you possess a criminal history or drug and alcohol records? Yes No

If yes, please explain:


Additional Comments

Additional comments, if any:


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*I Agree:   

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