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6007 South Redwood Road, Salt Lake City, UT 84123
Mon-Thurs: 9 AM - 5 PM, Fri: 9 AM - 2 PM
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 * Social Security Assessment
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Schedule a Consultation!801.328.5600


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Social Security Assessment
Social Security Assessment
Name

How old are you?

Are you currently working?

What is the last date you worked?

Have you applied for Social Security Disability previously?

Out of the last 10 years, have you worked at least 5 of those yearsfull time?

Have you looked at your earnings report from SocialSecurity?

What medical conditions prevent you from working?

Are you currently seeing a Physician for your conditions?

How long have you been seeing this doctor?

Did this doctor encourage you to apply for disability?

Could you work at a different occupation? What would that jobbe?

What is your current occupation?

What city do you live in?

What is your phone number?

Do you have an email address?

Education
Special education resource
High School or GED
Some college, no degree
4+ years college
Past 10 Years Work Exertion Includes
Did not work
Sedentary
Light
Medium
Heavy
Self Employment
Other Information
Honorable Discharge
Less than Honorable Discharge
I have a VA rating for disability
Frequency of Medical Treatment
Currently being treated by a Primary Care Physician who is a PA
Currently being treated by a Primary Care Physician who is an MD
Currently being treated by a Specialist
No treatment within one year
No treatment in the last threeyears
Is your Doctor cooperative in helping you with information for aclaim?
Yes
No
Medical Conditions (physical)
Back pain with MRI within 2 years
Back pain with MRI longer than 2 years ago
Failed backsurgery
Hip problem
Knee problem
Carpal TunnelSyndrome
Arthritis ofHands
Arthritis inAnkles/Feet
Arthritis/tear inshoulder/shoulders
Blind 20/200 orworse
Vision problems butnot blind
Deafness
Cardiomyopathy
COPD/Asthma
Oxygen 24/7
Congestive HeartFailure
Blocked arteries withpast bypass surgery
Liver disease
Hepatitis C
Low body weight with aBMI less than 17
Inflammatory boweldisease (IBS)
Crohn’s Disease
Kidneyproblems
Skin problems
Blood problems
Neurological Conditions
Stroke
Migraines / Cluster Headaches
Seizures (grand mal)
Seizures (petit-mal)
Parkinson’s Disorder
Alzheimer’s Disorder
Multiple Sclerosis
Muscular Dystrophy
Post-polio
Traumatic Brain Injury within last 4 years
Traumatic Brain Injury prior to 4 years ago
Immune System Disorders
Lupus
Mixed Connective Tissue Disorder
Sjogrens Syndrome
Fibromyalgia with treating doctor
Fibromyalgia without treating doctor
Chronic Fatigue Syndrome
HIV / AIDS
Rheumatoid Arthritis
Ankylosing Spondylitis
Psoriatic Arthritis
Other
Other important facts
Obesity with a BMI greater than 40
Use of a cane/walker/wheelchair
History of a transplant
Any cancer diagnosed within the last year?
Psychiatric and Mental Health
Verified regular treatment with a psychologist or psychiatrist
Regular treatment with a LCSW or APRN
Regular treatment with a LMFT/CMHC
Irregular or no treatment for mental health conditions
Depression
Bipolar
Generalized Anxiety
Agoraphobia (difficulty leaving house)
Panic attacks
PTSD
Schizophrenia
Schizoaffective Disorder
Intellectual Difficulty (IQ of less than 70)
Borderline IQ (IQ between 70 – 80)
Learning Disorders
Autism Spectrum Disorder
Personality Disorder
ADD/ADHD
OCD
Somatoform Disorder
Inpatient Stay for any mental treatment within the last year
Electro Convulsive Therapy
Support
Do you have family support to help you emotionally?
Do you have a spouse who is providing income/insurance?
Did you need help from a family member to do this assessment?
Are you able to read?
Is English a second language for you?
Submit Clear

SOCIAL SECURITY ASSESSMENT
Please find the attached SOCIAL SECURITY ASSESSMENT in the PDF format for Utah
Disability PC .

UTAH DISABILITY P C

We can help you navigate the complicated legal process of filing for the
compensation you deserve.

6007 South Redwood Road, Salt Lake City, UT, 84123



801.328.5600
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Friday: 9 AM - 2 PM
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