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What is your current age?
___________________
Highest grade completed in school? ___________ .
When did your impairment stop you from working?
_____________
Are you seeing a medical source for treatment of your impairments?
_____________________
Does your impairment interfere with your ability to do normal
activities? _________________
Do you have multiple serious impairments? _______________
Do you have both a mental and physical impairment? ___________
Has your condition required surgery?
___________ .
Have you had one or more hospitalizations as a result of your
impairment? _______________
Are you taking a medication for your condition that has caused
unpleasant side effects? _________
Does your impairment restrict your ability to stand or walk?
____________ .
Does your condition restrict your ability to sit? _____________
Does your condition cause severe pain? ____________
Does your impairment restrict the use of your hands?
____________ .
Does your impairment significantly reduce your ability to see?
_______________ .
Does your impairment significantly reduce your ability to hear?
______________
Has your impairment resulted in the loss of an employment skills
_______________
Has your impairment caused a physical deformity? _____________ .
Have you experienced a decline in your ability to memorize or
concentrate? ___________
Do you feel your condition is worsening with time? _________________
Please list all impairments that you
feel have reduced your ability to work.
__________________________________________________________________
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