Please answer each question below as honestly as possible:
What is your current age? ___________________ Highest grade completed in school? ___________ . When did your impairment stop you from working? _____________ Are you seeing a medical source for treatment of your impairments? _____________________ Does your impairment interfere with your ability to do normal activities? _________________ Do you have multiple serious impairments? _______________ Do you have both a mental and physical impairment? ___________ Has your condition required surgery? ___________ . Have you had one or more hospitalizations as a result of your impairment? _______________ Are you taking a medication for your condition that has caused unpleasant side effects? _________ Does your impairment restrict your ability to stand or walk? ____________ . Does your condition restrict your ability to sit? _____________ Does your condition cause severe pain? ____________ Does your impairment restrict the use of your hands? ____________ . Does your impairment significantly reduce your ability to see? _______________ . Does your impairment significantly reduce your ability to hear? ______________ Has your impairment resulted in the loss of employment skills _______________ Has your impairment caused a physical deformity? _____________ . Have you experienced a decline in your ability to memorize or concentrate? ___________ Do you feel your condition is worsening with time? _________________
