Get SSA-3381 2005

Form SSA-3381 4-2005 Use prior editions IN OUT OVER F. Medications you take and why you take them. If prescribed provide the doctor s name. MEDICAL AND JOB WORKSHEET - ADULT Help us to help you Completing this worksheet will help you get ready for the interview. Or you can complete the Adult Disability Report on the Internet at www. socialsecurity. gov/adultdisabilityreport. We may ask for additional information at the interview. If you need more space use blank sheets of paper. A. Illnesses injuries or conditions limiting your ability to work. B. Date you became unable to work because of your medical condition month/day/year. C. If applicable Medical Assistance Number Medicaid or other. D. Doctor/HMO/therapist/ or other person who treated your illnesses injuries or conditions or who you expect to treat you in the future. NAME ADDRESS ZIP CODE and PHONE NUMBER PATIENT I. D. NUMBER DATE FIRST SEEN LAST E* Hospitals clinics or emergency rooms you visited or expect to visit because of your illnesses injuries or conditions. NAME OF MEDICINE WHY YOU TAKE IT PRESCRIBED BY G* Medical tests you had or are going to have in the future. NAME OF TEST PLACE OF TEST PERSON WHO SENT YOU H. Jobs you had in the 15 years before you became unable to work because of your illnesses JOB TITLE e*g* cook TYPE OF BUSINESS e*g* restaurant DATES WORKED month/year FROM TO HOURS PER DAY WEEK RATE OF PAY per hour/ week/year. MEDICAL AND JOB WORKSHEET - ADULT Help us to help you Completing this worksheet will help you get ready for the interview. Or you can complete the Adult Disability Report on the Internet at www. socialsecurity. gov/adultdisabilityreport. Or you can complete the Adult Disability Report on the Internet at www. socialsecurity. gov/adultdisabilityreport. We may ask for additional information at the interview. If you need more space use blank sheets of paper. We may ask for additional information at the interview. If you need more space use blank sheets of paper. A. Illnesses injuries or conditions limiting your ability to work. B. Date you became unable to work because of your medical condition month/day/year. A. Illnesses injuries or conditions limiting your ability to work. B. Date you became unable to work because of your medical condition month/day/year. C. If applicable Medical Assistance Number Medicaid or other. D. Doctor/HMO/therapist/ or other person who treated your illnesses injuries or conditions or who you expect to treat you in the future. C. If applicable Medical Assistance Number Medicaid or other. D. Doctor/HMO/therapist/ or other person who treated your illnesses injuries or conditions or who you expect to treat you in the future. NAME ADDRESS ZIP CODE and PHONE NUMBER PATIENT I. D. NUMBER DATE FIRST SEEN LAST E* Hospitals clinics or emergency rooms you visited or expect to visit because of your illnesses injuries or conditions. NAME OF MEDICINE WHY YOU TAKE IT PRESCRIBED BY G* Medical tests you had or are going to have in the future. NAME OF TEST PLACE OF TEST PERSON WHO SENT YOU H. Jobs you had in the 15 years before you became unable to work because of your illnesses JOB TITLE e*g* cook TYPE OF BUSINESS e*g* restaurant DATES WORKED month/year FROM TO HOURS PER DAY WEEK RATE OF PAY per hour/ week/year. .