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Disability Report Form Guide (Adults)
Disability Report Form Guide (Adults)

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Section 4 - Information About Your Medical Records

  General Information About Section 4
A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions that limit your ability to work?
B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems that limit your ability to work?
C. List other names you have used on your medical records.
D. List each DOCTOR / HMO / THERAPIST / OTHER.
E. List each HOSPITAL / CLINIC.
F. Does anyone else have medical records or information about your illnesses, injuries, or conditions?
 
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Last reviewed or modified Wednesday Apr 01, 2009
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