Free Social Security Disability Claim Evaluation Form

Social Security Disability Claim Evaluation Form (DO121)
Assessment provided by
Social Security Disability Attorney Stephanie O. Joy, Esq.

1. Your Contact Information

A. Name:

B. Address (Full Mailing):

C. Email:

D. Phone:

2. Background Information

B. Date of Birth (optional):

A. Age:

C. Marital status:

D. Social Security Number (optional):

Single never Married

Single after Divorce

Married and not separated

Separated

Widowed and Single

E. Working Status:

F. Minor Children:

Yes

Currently still working Full Time, despite the difficulty

Currently working Part Time only, despite difficulty

No longer working, and I stopped approximately (pick one):

G. Have you filed for SSD or SSI before? If
so, is your claim still open or on appeal? -->

3. Your Medical Problems that Disable You:

A. Describe your medical problems here:

B. PHYSICAL LIMITATIONS: Click all that apply.

Walking/Standing: I can't walk very far or for very long, or I can't stand for long, due to pain/fatigue,
poor balance etc.

Sitting: I can't sit for long in a regular work type chair due to pain in back, hips, legs, feet or neck.

Bending/Stooping/Twisting at the waist - is limited for me.

My hand's and/or fingers don't work so well due to pain, stiffness, numbness or other symptom

Respiratory problems, shortness of breath, etc.

C. Explain any additional limitations here:

D. MENTAL LIMITATIONS: Do you have an mental limitations? (Depression, poor concentration, bipolar,
constantly sleepy, Anxiety/Phobias, etc.)

That's it! You are done. Just click submit, and I will contact you
shortly to let you know!