Questionnaire First Name * Last Name * Phone Number (s) * Street Address * City * State * Zip Code * Email Year of birth * What was the last day you worked? * JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 Have you applied for SSDI? Yes No Please describe your disabilities * How many times have you seen doctors in the last 12 months? * Have you already applied for Social Security Disability or SSI? * Yes No If so, when did you apply? JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 What was the last letter you received from Social Security? When did you receive it? JanFebMar AprMayJun JulAugSep OctNovDec 12345678910111213141516171819202122232425262728293031 Do you currently have an attorney or representative? * Yes No I understand that by completing this questionnaire I am not creating an attorney-client relationship * Yes No

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