Form Dhs 1277 - Service Questionnaire Page 9

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Education information
If you attended any college/trade school or other trainings:
School name
Begin date
End date
Degree/certification or area of study
Are you currently attending college?
Yes
No
If yes, where do you attend college?
Are you currently in default on any prior student loans?
Yes
No
Counselor notes:
Medical information
Have you ever had a head injury or been knocked unconscious?
Yes
No
If yes, please explain:
Do you have any restrictions from your doctor about working?
Yes
No
Counselor notes:
Medical providers
Vocational Rehabilitation (VR) will need your help to get your medical records. We need them to
document your medical condition(s); identify your limitations; determine if you are eligible
for our program; plan work goals; and identify services you may need to help you get or keep
a job. If there is not enough space, list additional providers on a separate piece of paper.
Please list all doctors, clinics, counselors or therapists you have seen in the past or are seeing now
for treatment related to your disability. Include any physical exams and/or learning disability testing.
Medical provider/clinic name:
Phone number:
Address:
Treatment for:
Are you still seeing this provider?
Yes
No
Most recent visit:
Page 9 of 10
DHS 1277 (10/2016)

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