Information Checklist

1. Doctors’ names, specialties, addresses, phone numbers, dates of treatment, type of treatment, and doctor’s belief as to whether or not you are disabled.

2. Hospital names, addresses phone numbers, dates of admission, type of treatment.

3. Medications-including the date first prescribed, dosage, reason for taking, and doctor's name who prescribed medication.

4. Doctors' reports about any physical or mental limitations.

5. History or statement of any medical tests you have had in the last two (2) years.

6. Your work history for the last fifteen (15) years – including your rate of pay and the name, address, and telephone number of employer(s)

7. A brief statement as to why you feel that you are unable to do any type of work.

8. Any information concerning a Workers’ Compensation claim that you presently have or have had in the last fifteen (15) years.

9. Any information concerning a previous Social Security filing or denial and whether or not you have been before a Social Security Administrative Law Judge.

10. Military information

11. Marriage information – including names and ages of any children

Please provide information as completely as possible. Do not hesitate to contact this office is you have any questions, comments or concerns.

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