Form Ssa-3381 - Medical And Job Worksheet - Adult Page 2
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2E. Medicines
Please list any medicines you take and why you take them. If prescribed, please provide the
doctor’s name.
NAME OF MEDICINE
WHY YOU TAKE IT
PRESCRIBED BY
F. Medical Tests
Please list any medical tests you had or are going to have in the future.
NAME OF TEST
PROVIDER WHO SENT YOU
DATE(S)
G. Job History
List the jobs (up to 5) that you have had in the 15 years before you became unable to work
because of your physical or mental conditions. List your most recent job first.
DATES WORKED
RATE OF PAY
JOB TITLE
TYPE OF BUSINESS
HOURS
DAYS PER
FROM
TO
(e.g., cook)
(e.g., restaurant)
PER DAY
WEEK
Amount Frequency
Mo/Yr
Mo/Yr
Bring this worksheet to your appointment or have it with you if your appointment is by
telephone. Do not delay filing your application, even if you do not have all of the information.
We will help you get any missing information.
Form SSA-3381 (12-2009) Destroy prior editions
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Parent category: Legal