Disability Benefits Medical Questionnaire
Please complete this questionnaire to help us assess your eligibility for disability benefits. All information will be kept confidential.
Applicant's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary diagnosis or medical condition?
*
How long have you had this condition? (e.g., 2 years, since birth)
*
Please indicate the severity of your symptoms in the following areas:
*
Rows
Severity (None, Mild, Moderate, Severe)
Pain
None
Mild
Moderate
Severe
Mobility
None
Mild
Moderate
Severe
Fatigue
None
Mild
Moderate
Severe
Concentration
None
Mild
Moderate
Severe
Vision
None
Mild
Moderate
Severe
Hearing
None
Mild
Moderate
Severe
How does your condition affect your ability to perform daily activities? (Select all that apply)
*
Walking or moving around
Personal care (bathing, dressing, grooming)
Household tasks (cooking, cleaning, shopping)
Working or attending school
Social interactions
None of the above
Other
List your current medications and treatments (include dosage and frequency if known):
Healthcare Provider's Name and Contact Information
Please provide any additional information about your medical condition or limitations:
Applicant's Signature
*
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