Form Ssa-3381 - Medical And Job Worksheet - Adult

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MEDICAL AND JOB WORKSHEET - ADULT
Please do not mail this worksheet to your local office.
Did you know that you can start the application process online?
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Complete this worksheet to get ready for the appointment or when filing online. This worksheet
is not the application for Social Security disability benefits. You should bring this worksheet to
your appointment or have it with you if your appointment is by telephone.
A. Medical Conditions
List all of the physical or mental conditions (including emotional or learning problems) that limit your
ability to work. If you have cancer, please include the stage and type. List each condition separately.
CONDITIONS
1.
2.
3.
4.
5.
B. If you are not working, when did you stop working?
C. Height without shoes:_______feet_____inches
Weight without shoes: _____ pounds
D. Medical Sources
Please list any doctors, hospitals, clinics, therapists, or emergency rooms you have visited
because of your conditions.
DATE FIRST
DATE LAST
PHONE NUMBER
SEEN OR
SEEN OR
NAME
ADDRESS
(with area code)
ADMISSION
DISCHARGE
DATE
DATE
OVER
Form SSA-3381 (12-2009) Destroy prior editions

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