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? Visit www.socialsecurity.gov/applyfordisability for more information! 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.

NAME

ADDRESS

PHONE NUMBER (with area code)

DATE FIRST SEEN OR ADMISSION DATE

DATE LAST SEEN OR DISCHARGE DATE

And much more...