DIB and SSD Claims
Disabled Widow Benefits
Disabled Adult Child Claims
Can I Work
Dire Need Cases
Disability – Initial Application
Hearings with a Judge
Medical Record Evidence
Over Age 50 Claims
Social Security Disability
Social Security Assessment
Social Security Assessment
How old are you?
Are you currently working?
What is the last date you worked?
Have you applied for Social Security Disability previously?
Out of the last 10 years, have you worked at least 5 of those years full time?
Have you looked at your earnings report from Social Security?
What medical conditions prevent you from working?
Are you currently seeing a Physician for your conditions?
How long have you been seeing this doctor?
Did this doctor encourage you to apply for disability?
Could you work at a different occupation? What would that job be?
What is your current occupation?
What city do you live in?
What is your phone number?
Do you have an email address?
Special education resource
High School or GED
Some college, no degree
4+ years college
Past 10 Years Work Exertion Includes
Did not work
Less than Honorable Discharge
I have a VA rating for disability
Frequency of Medical Treatment
Currently being treated by a Primary Care Physician who is a PA
Currently being treated by a Primary Care Physician who is an MD
Currently being treated by a Specialist
No treatment within one year
No treatment in the last three years
Is your Doctor cooperative in helping you with information for a claim?
Medical Conditions (physical)
Back pain with MRI within 2 years
Back pain with MRI longer than 2 years ago
Failed back surgery
Carpal Tunnel Syndrome
Arthritis of Hands
Arthritis in Ankles/Feet
Arthritis/tear in shoulder/shoulders
Blind 20/200 or worse
Vision problems but not blind
Congestive Heart Failure
Blocked arteries with past bypass surgery
Low body weight with a BMI less than 17
Inflammatory bowel disease (IBS)
Migraines / Cluster Headaches
Seizures (grand mal)
Traumatic Brain Injury within last 4 years
Traumatic Brain Injury prior to 4 years ago
Immune System Disorders
Mixed Connective Tissue Disorder
Fibromyalgia with treating doctor
Fibromyalgia without treating doctor
Chronic Fatigue Syndrome
HIV / AIDS
Other important facts
Obesity with a BMI greater than 40
Use of a cane/walker/wheelchair
History of a transplant
Any cancer diagnosed within the last year?
Psychiatric and Mental Health
Verified regular treatment with a psychologist or psychiatrist
Regular treatment with a LCSW or APRN
Regular treatment with a LMFT/CMHC
Irregular or no treatment for mental health conditions
Agoraphobia (difficulty leaving house)
Intellectual Difficulty (IQ of less than 70)
Borderline IQ (IQ between 70 – 80)
Autism Spectrum Disorder
Inpatient Stay for any mental treatment within the last year
Electro Convulsive Therapy
Do you have family support to help you emotionally?
Do you have a spouse who is providing income/insurance?
Did you need help from a family member to do this assessment?
Are you able to read?
Is English a second language for you?
Utah Disability, P.C.
6007 South Redwood Road, Salt Lake City, UT 84123
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