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Get SSA-3381 2009-2021

NAME Form SSA-3381 12-2009 Destroy prior editions ADDRESS PHONE NUMBER with area code DATE FIRST SEEN OR ADMISSION DATE DATE LAST DISCHARGE OVER E. Medicines doctor s name. 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 B. If you are not working when did you stop working C. Height without shoes feetinches D. Medical Sources Please list any doctors hospitals clinics therapists or emergency rooms you have visited because of your conditions. NAME OF MEDICINE F* WHY YOU TAKE IT PRESCRIBED BY Medical Tests NAME OF TEST G* PROVIDER WHO SENT YOU Job History List the jobs up to 5 that you have had in the 15 years before you became unable to work JOB TITLE e*g* cook TYPE OF BUSINESS e*g* restaurant DATES WORKED FROM Mo/Yr TO HOURS DAYS PER PER DAY WEEK RATE OF PAY Amount Frequency Bring this worksheet to your appointment or have it with you if your appointment is by telephone. Do not delay filing your application even if you do not have all of the information* We will help you get any missing information*. 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. 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. 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 B. If you have cancer please include the stage and type. List each condition separately. CONDITIONS B. If you are not working when did you stop working C. Height without shoes feetinches D. Medical Sources Please list any doctors hospitals clinics therapists or emergency rooms you have visited because of your conditions. NAME OF MEDICINE F* WHY YOU TAKE IT PRESCRIBED BY Medical Tests NAME OF TEST G* PROVIDER WHO SENT YOU Job History List the jobs up to 5 that you have had in the 15 years before you became unable to work JOB TITLE e*g* cook TYPE OF BUSINESS e*g* restaurant DATES WORKED FROM Mo/Yr TO HOURS DAYS PER PER DAY WEEK RATE OF PAY Amount Frequency Bring this worksheet to your appointment or have it with you if your appointment is by telephone. Do not delay filing your application even if you do not have all of the information* We will help you get any missing information*. .

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