Social Security Disability Intake Questionnaire

Do you have any minor children?

Have you ever received a worker's compensation claim?

Special Ed ant any time?

Have you already started a social security claim?

Did you apply for:
Check all that apply.

Have you ever been diagnosed with T.B. (Tuberculosis)?

Have you ever been diagnosed with Hepatitis B or C?

Is the Hepatitis B or C Active?

Have you ever been hospitalized for your illness or injuries?

Can you effectively read and write? (Can you read a newspaper or write a letter?)

Do you have a criminal record as a juvenile or as an adult?

Have you ever served any time in jail or D.O.C?

Do you owe any money for child support or student loans?

Did you receive any letters from State on child support?

Have you received any letter from the Federal Government or IRS about student loans?

Please verify that you have read the disclaimer. I have read the disclaimer.