Name

First Name

Last Name

Phone

(###)

###

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Address

Age

Highest grade completed:

Date you last worked:

Types of work you have done in the past 15 years:

Conditions preventing you from working:

Treating doctors:

Have you applied for disability benefits? If yes, please continue.

Have you been denied? If yes please continue.

Have you requested Reconsideration?

If no, when were you denied?

Have you been denied reconsideration. If yes please continue.

Have you requested a hearing?

If yes, when? Do you have a hearing date?

If no, when was your Reconsideration denied?

Have you had a hearing with an Administrative Law Judge?

Law Office of Attorney Jay Rothlein

Social Security Questionnaire