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State: Michigan
Place of Birth
  State:  
Gender:



Marital Status:







Contact Person Information
(A person who knows how to contact you at all times)

State:  


Education Information



Have you ever attended special
education classes?





Have you participated in any job
training or vocational
rehabilitation programs?





Work Information

Work History:





(see chart below)

Sedentary - Lift max 10lbs, sit 6-8hrs/day, stand 2-8hrs, never crouch, rarely kneel, full use of hands.   Light - Lift max 20lbs, 10 frequently, stand 6-8hrs, occasional sitting, occasional stooping, never crouching, some kneeling.   Medium - Lift max 50lbs, 25 frequently, stand 6-8hrs, frequent stooping, crouching, some kneeling, some climbing.   Heavy - Lift 100lbs occasionally, 50 frequently, stand 6-8hrs, frequent stooping, crouching, kneeling, pushing/pulling.

Briefly describe your most recent
work as well as 15 years in the
past (if applicable).




Medical Information

Briefly describe your disabling
condition and the symptoms
you experience due to your
disabling condition.



Has your disability lasted
at least one year?



Will it last another 12
months?



Medical Treatment: Do you see your doctor(s)
at least every 3 to 6 months?


Last Appointment: When was the last appointment with your
primary doctor?

Do you currently have
medical insurance?



Please list the addresses and phone
numbers for any and all doctors or
specialists seen for your
disabling condition(s)


  What medical tests have you had or are
going to have in the future?


List any and all medications you are taking
for your disabling condition


  List any and all medication side effects
you are experiencing


  List any and all conditions that causes
you severe pain


Limitations walking
and/or standing?



Limitations sitting?


Limitations using hands?


Current Status of SSA Disability Claim, if Applicable
(Your answers to the questions below indicate whether or not you have previously filed an SSA disability claim or if you have recently filed for and have a current SSA disability claim
in process and the status of that claim.)






Do you have a copy of your
"Notice of Disapproved Claim"...?





Have you filed an
ALJ Hearing Appeal?





 
 


Other Information and Submit Form




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