Disablity Advocates, Inc.
    Instructions: Please complete all sections to the best of your knowledge.
    Name:
    Social Security #:
    Street Address:
    City: State:      Zip:
    Phone:
    Email:
    Date of Birth: Age:
    Date Last Worked:
    Have you worked 5 of last 10 years with Social Security tax withheld? Yes/No:
    Marital Status:
    Briefly describe the illness or injuies that interfere with your ability to work:
     
    Please provide us with information on doctors that you see consistently, who you think would support your claim.
    (We will write each doctor you provide to get support for your claim.)
    Name of Physician:
    Address:
    City:      State:     Zip:
    Phone:     Date Last Seen:
    Type of Treatment:

    Name of Physician:
    Address:
    City:      State:     Zip:
    Phone:     Date Last Seen:
    Type of Treatment:

    Name of Physician:
    Address:
    City:      State:     Zip:
    Phone:     Date Last Seen:
    Type of Treatment:

    Name of Physician:
    Address:
    City:      State:     Zip:
    Phone:     Date Last Seen:
    Type of Treatment:
     
    Please provide us with information on your employment history for the past 15 years so that we can prove you can not return to former jobs you have held in the past. (Do the best you can on the dates, the job titles are the most important information.)
    Company/Job Title:      From:      To: (Month/Year)
    Company/Job Title:      From:      To: (Month/Year)
    Company/Job Title:      From:      To: (Month/Year)
    Company/Job Title:      From:      To: (Month/Year)
    Company/Job Title:      From:      To: (Month/Year)
    Company/Job Title:      From:      To: (Month/Year)
     
    Have you ever had lab test, xrays, MRI's or surgery that deal with your current problems? If so please name the test, when it was done and where (if you remember):
    How much formal education do you have:

    Have you ever applied for any of the following:
    Worker's Compensation: Yes/No
    Veteran's Benefits: Yes/No
    Social Security Disability: Yes/No

    Do you have medical insurance: Yes/No
    If yes, with what company?