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Social Security Intake Questionnaire

New Social Security Clients Questionnaire

MM slash DD slash YYYY
Mailing Address*
Enter your Mailing Address

Education

Can you understand the newspaper?
Can you make change?
Other Educational / Vocational Training:

CLAIM FOR BENEFITS

Have you filed a claim for benefits?

FUNCTIONAL LIMITATIONS

Are you under doctor's care at this time?
Any problems lifting?
Do you have any other functional limitations?