Social security intake questionnaireRichard Cruz2021-05-03T07:17:18-07:00Please use the form below to submit some information to us.We respect your privacy concerns and this transmission is encrypted.We promise not to share this data with anyone.Social Security Intake QuestionnaireNew Social Security Clients QuestionnaireFirst Name*Last Name*Date* MM slash DD slash YYYY Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Enter your Mailing AddressTelephone #*Current AgeEducationClient's EducationIlliterateUnable to speak EnglishLess than 6th GradeLess than 12th GradeCompleted High SchoolCollege Years CompletedDegrees EarnedAny Problems Reading and Writing?YesNoCan you understand the newspaper? Yes NoCan you make change? Yes NoOther Educational / Vocational Training: Yes NoCLAIM FOR BENEFITSHave you filed a claim for benefits? Yes NoFUNCTIONAL LIMITATIONSAre you under doctor's care at this time? Yes NoWhat disabilities do you have that keep you from working?What type of treatment are you undergoing right now?How long can you sit at one time?How long can you stand at one time?How long can you alternate, sit and/or stand at one period of time?Any problems kneeling?Any problems bending?Any problems lifting? Yes NoAny problems lying down?Do you have any other functional limitations? Yes NoWhere did you hear about the law offices of Ronald Metzinger & Associates?
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