Complete Social Security Disability)

Quatman Law Office
Janice A. Quatman, Attorney at Law

317 N. Elizabeth Street 419-229-0023
Lima, Ohio 45801-4304 419-229-5342 (fax)
RE: Social Security Case
Dear Sir/Madam:
You have recently set an appointment with me at my office. When you come, please bring all of
the following documents:
• All of you Social Security papers (including denial letters, appeal forms, and any papers
relating to earlier application)
• Annual Earnings Records letter from the Social Security Administration (birthday letter)
• Any hospital or medical records (already in your possession, do not request additional
medical records)
• Any doctor’s business or appointment cards
• The enclosed questionnaire, filled out in its entirety
• Business cards of treating physicians
If you have been involved in other disability cases (such as short or long term disability, worker’s
compensation, etc.) please bring all papers related to those cases also. If you received Unemployment
Compensation during any time you claim to be disabled, bring papers related to your Unemployment
Compensation benefits.
Be very careful about the appeals deadlines. Please appeal any denial letters as soon as possible.
Please submit your appeal before the date of our appointment. You may appeal by going to any social
security office. Don’t forget to bring a copy of the appeal papers to our meeting.
** THE ENCLOSED QUESTIONNAIRE MAY TAKE SEVERAL HOURS TO COMPLETE. **
IF YOU DO NOT HAVE IT COMPLETED BY THE TIME OF YOUR APPOINTMENT

IN THIS OFFICE, PLEASE CALL AND RESCHEDULE.
Sincerely,
Janice A. Quatman
Attorney at Law
JAQ/tjh
Enclosure
Quatman Law Office
Janice A. Quatman, Attorney At Law
317 N. Elizabeth St. 3949 N. Main Street
Lima, Ohio 45801 Findlay, Ohio 45840
419-229-0023 419-422-4878
Appointment Date: _____________

Appointment Time: _____________
SOCIAL SECURITY CLAIM INTERVIEW INFORMATION
DATE: ___________ Referred by: ___________ Friend/Client Name

Interviewed By: _______________ ___________ Advertisement/Where
___________ Phone Book
WORKMENS COMP. YES NO ___________ Attorney’s Name
VETERAN: YES NO ___________ Doctor’s Name
PERSONAL HISTORY
Name:_____________________________________ Social Security Number: _______/_____/_______

Address:_________________________________________________________ (___Own ____ Rent)
Home Phone:_______________________________ Cell Phone:________________________________
Email Address:__________________________________ Date of Birth:_________________________
____ Male ____ Female Age ____ ______Weight ______ Height
Physical Address: ____________________________________________________________________

(If different than mailing address)
City, State & Zip: ____________________________________________________________________
Spouse’s Name: ______________________________ Spouse’s SSN ________/____/______________

___ Divorced ___ Married ___Separated ___Single Widowed spouse’s date of death____________
Children: ____ Yes ____ No If yes, please gives names and ages of children:
_____________________________, _____________________________, ________________________
_____________________________, _____________________________, ________________________
If any are minor children, are they in your custody? _____ Yes _____ No
EDUCATION
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Highest grade completed: ______ Grades repeated: _______ GED: _____ Yes _____ No
Were you in any special classes? ______ Yes _______ No
Can you read? ______English _________ Spanish ________ Other
Can you write? ______English _________ Spanish ________ Other
Add/Subtract? _____Yes ______No Multiply/Divide? ______ Yes ______ No
Can you make change? ______Yes ______ No
Special or vocational training? ______ Yes _______ No
If yes, type of training_________________________________________________________________
Did you ever go to vocational rehabilitation? ____Yes ____No
If so, when? ____________ Where? __________________________Case Worker: _______________
Military Service: _______Yes ______No If Yes, Dates: _____________________________________
Branch ___________________ Special Military Training ____________________________________
MONTHLY INCOME
Do you or your spouse receive any of the following? If so, please fill out the amounts.
YOU SPOUSE
Social Security $__________________ $_____________________

Unemployment $__________________ $_____________________
Private Pension $__________________ $_____________________
Short Term Disability $__________________ $_____________________
Long Term Disability $__________________ $_____________________
V.A. Pension $__________________ $_____________________
R.R. Retirement $__________________ $_____________________
Government Pension $__________________ $_____________________
Welfare/Food Stamps $__________________ $_____________________
Earned Income $__________________ $_____________________
Other: $__________________ $_____________________
Special Comments:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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PERSONAL INJURY ACCIDENTS
Any accidents (car accident, slip and fall, dog bite, other? Within the last five (5) years? ___Yes ___No
If yes, Dates: _____________________________ Attorney: __________________________________
If you need representation, George B. Quatman can help you with your accident case.
WORKER'S COMPENSATION ACCIDENTS
Do you have a claim for Worker's Compensation? ____ Yes ____ No

If yes, date of accident: _______________________
Benefit Amount $________________ ______Weekly _____Bi-weekly _____ Monthly W/C

Has case been settled? ____ Yes ____ No If yes, date of settlement: ____________________
Lump Sum $______________________________ Attorney's Name:__________________________
Attorney Address:________________________________ Phone #:__________________________
If case has settled, bring a copy of settlement agreement.
PRIVATE DISABILITY
Have you made a claim for Short Term or Long Term Disability through a private insurance company
(i.e, Unum, Aetna, etc.) _____ Yes _____No
************************************************************************************
************************************************************************************
************Claim Information: (Do Not Complete This Section) ***************************
Application Date:__________________ Office Signed up at _______________________________
Type of Claim: ____DIB ____ SSI _____Widow's _____Child’s _____Term.
Current Status: _____________________________________________________________________
Prior applications: _________________________ Outcome: _______________________________
DATE LAST WORKED: ____________________________________________________________
ONSET OF DISABILITY:__________________________ DLI Problem?_____________________
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-3-
WORK HISTORY
What was the date you last worked?______________

Did you stop working because of your medical condition? _____ Yes _____ No
Are you doing any work now either on a part-time basis,

as a volunteer or on a welfare work project? _____ Yes _____ No
If yes, what do you do? _______________________________________________________________
How many hours per week do you work?_____ How much do you earn each month? $____________
************************************************************************************
Please list every job you have had in the LAST 15 YEARS. Start with most recent job. Include
attempts since the onset of disability. (Bring copy of resume if available)
(1) LAST EMPLOYER ____________________________________ Job Title_________________

Address:______________________________________________________________________
Years Employed _______________ Date Started Job__________ Date Job Ended___________
Job Description: (your duties)______________________________________________________
HOURS PER DAY SITTING _____ HOURS PER DAY STANDING ____
WEIGHT FREQUENTL Y LIFTED: _______________________________________________
Exertional Requirements:_________________________________________________________
Machines, Tools, Special Equipment Used: __________________________________________
Supervised? ___Yes ___No If Yes, How Many? ____________________________________
Work Along side? ____ Yes ____No
Do Reports/Paperwork? ____ Yes ____ No If yes, what kind? ___________________________
Reason stopped working:_________________________________________________________
Unemployment received? ____ Yes ____ No If yes, how long? ________________________
************************************************************************************

Address:______________________________________________________________________
************************************************************************************
-4-
Address:______________________________________________________________________
***********************************************************************************
Address:______________________________________________________________________
***********************************************************************************
Address:______________________________________________________________________
************************************************************************************
Address:______________________________________________________________________
-5-
If you have more than six employers, please attach a list.
MEDICAL PROBLEMS (Symptoms)
What medical conditions keep you from working? Start with the worst, and include both physical and
mental conditions.
1 _____________________________________ 2_____________________________________
3 _____________________________________ 4_____________________________________
5 _____________________________________ 6_____________________________________
7 _____________________________________ 8_____________________________________
9 _____________________________________ 10 ___________________________________
11 ____________________________________ 12 ___________________________________
13 ____________________________________ 14 ___________________________________
Symptoms and complaints:_____________________________________________________________

Limitation(s) imposed by treating doctor __________________________________________________
___________________________________________________________________________________
FUNCTIONAL CAPACITY
How long can you sit?__________________ Stand?______________________

How far can you walk?____________________ Can you bend?____ Yes ____ No
Can you kneel? ____ Yes ____ No Can you crawl? ____ Yes ____ No
Can you stoop? ____ Yes ____ No Can you climb? ____ Yes ____ No
How many pounds can you lift? _________ Can you reach over your head? ____ Yes ____ No
-6-
MEDICAL TREATMENT
(Attach Business Card If Available) Doctor's Name:
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
Condition treated for:__________________________________________________________________
Dates of treatment: From_____________________________ To ______________________________
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
Doctor’s Name_______________________________________________________________________
Address:____________________________________________________________________________
Phone:__________________________________________Fax:________________________________
If you have more doctors, please attach list.
MENTAL OR PSYCHIATRIC TREATMENT, COUNSELING

(Attach Business Card if Available)
Psych Doctor's Name /Psych Clinic:______________________________________________________

Address:____________________________________________________________________________
Phone: _________________________________________ Fax:________________________________
Condition treated for: _________________________________________________________________
Dates of treatment: From___________________________ To _________________________________
-7-
Address:____________________________________________________________________________
Phone: _________________________________________ Fax:________________________________

Address:____________________________________________________________________________
Phone: _________________________________________ Fax:________________________________
Do any of your doctors know you are applying for disability? ___Yes ____ No
If so, who would be willing to fill out forms to help you with your claim?
____________________________________________________________________________________
If you have more doctors, please attach a list.
HOSPITAL ADMISSIONS OR ER VISITS/SURGERIES

Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
Condition treated for: __________________________________________________________________
Dates of treatment: From ____________________________ To ________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
-8-
Phone: ___________________________________ Fax:______________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
Hospital:____________________________________________________________________________
Address: ____________________________________________________________________________
Phone: ___________________________________ Fax:______________________________________
If you have additional hospital visits, please attach list.
MEDICATIONS
DRUG/DOSAGE REASON/CONDITION DOCTOR HOW LONG SIDE EFFECTS
1._____________ __________________ _______________ __________ __________________
2._____________ __________________ _______________ __________ __________________
3._____________ __________________ _______________ __________ __________________
4._____________ __________________ _______________ __________ __________________
5._____________ __________________ _______________ __________ __________________
6._____________ __________________ _______________ __________ __________________
7._____________ __________________ _______________ __________ __________________
8._____________ __________________ _______________ __________ __________________
9._____________ __________________ _______________ __________ __________________
10._____________ __________________ _______________ __________ __________________
11._____________ __________________ _______________ __________ __________________
12._____________ __________________ _______________ __________ __________________
-9-
EMOTIONAL/SOCIAL HISTORY
CONSTANTLY FREQUENTLY OCCASIONALLY RARELY NEVER
Nervous _____________ ____________ _______________ _________ __________

Tense/shaky _____________ ____________ _______________ _________ __________
Irritable _____________ ____________ _______________ _________ __________
Depressed/Tearful _____________ ____________ _______________ _________ __________
Anxious/Fearful _____________ ____________ _______________ _________ __________
Stay by Self _____________ ____________ _______________ _________ __________
Short-Tempered _____________ ____________ _______________ _________ __________
Easily Change Moods _____________ ____________ _______________ _________ __________
Usually Tired/Weak _____________ ____________ _______________ _________ __________
Lose interest doing things __________ ____________ _______________ _________ __________
Do not like crowds _____________ ____________ _______________ _________ __________
Do not like socializing _____________ ____________ _______________ _________ _________
Memory Difficulties _____________ ____________ _______________ _________ __________
Difficulty dealing w/stress _________ ____________ _______________ _________ __________
Suicide thoughts _____________ ____________ _______________ _________ __________
Had visions _____________ ____________ _______________ _________ __________
Do you drink alcohol? _____________ ____________ _______________ _________ __________
Do you smoke? _____________ ____________ _______________ _________ __________
Any alcohol/drug related arrests? _____ Yes _____ No

If yes, when:_________________________________________________________________________
Any other arrests? ____ Yes ____ No
If yes, when:_________________________________________________________________________
Did you serve jail time? ____ Yes ____ No
If yes, where & when__________________________________________________________________
Describe sleeping habits and change since disability began: ___________________________________

___________________________________________________________________________________
Describe appetite and changes since disability began: _______________________________________
___________________________________________________________________________________
Has your personality, attitude or behavior changed since you became disabled? ____ Yes ____ No
If so, Please explain __________________________________________________________________
Are you presently able to:
YES NO Limitations/How Often

Drive a car _____ _____ ____________________________
Take a daily bath/shower _____ _____ ____________________________
Get dressed everyday _____ _____ ____________________________
Fix your own meals _____ _____ ____________________________
Do dusting/cleaning _____ _____ ____________________________
Wash Dishes _____ _____ ____________________________
- 10 -
YES NO Limitations/How Often
Grocery Shopping _____ _____ ____________________________

Go to Church _____ _____ ____________________________
Go out to dinner or movies _____ _____ ____________________________
Visit friends/relatives _____ _____ ____________________________
Watch T.V. _____ _____ ____________________________
Do yard work _____ _____ ____________________________
Handle finances _____ _____ ____________________________
ADDITIONAL CONTACTS
Please provide us with the names/addresses/phone numbers of three friends/relatives who know you
well and can give us additional information:
1. Relative/Friends Name: ____________________________________________________

Address: ____________________________________________________
City, State, Zip: ____________________________________________________
Home Phone: ____________________________________________________
Cell Phone: ____________________________________________________

Address: ____________________________________________________
City, State, Zip: ____________________________________________________
Home Phone: ____________________________________________________
Cell Phone: ____________________________________________________

Address: ____________________________________________________
City, State, Zip: ____________________________________________________
Home Phone: ____________________________________________________
Cell Phone: ____________________________________________________
- 11 -

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Quatman Law Office

Janice A. Quatman, Attorney at Law

RE: Social Security Case

** THE ENCLOSED QUESTIONNAIRE MAY TAKE SEVERAL HOURS TO COMPLETE. **

IF YOU DO NOT HAVE IT COMPLETED BY THE TIME OF YOUR APPOINTMENT

Appointment Date: _____________

SOCIAL SECURITY CLAIM INTERVIEW INFORMATION

DATE: ___________ Referred by: ___________ Friend/Client Name

Name:_____________________________________ Social Security Number: _______/_____/_______

Physical Address: ____________________________________________________________________

Spouse’s Name: ______________________________ Spouse’s SSN ________/____/______________

Social Security $__________________ $_____________________

WORKER'S COMPENSATION ACCIDENTS

Do you have a claim for Worker's Compensation? ____ Yes ____ No

Benefit Amount $________________ ______Weekly _____Bi-weekly _____ Monthly W/C

If case has settled, bring a copy of settlement agreement.

What was the date you last worked?______________

Are you doing any work now either on a part-time basis,

(1) LAST EMPLOYER ____________________________________ Job Title_________________

(2) LAST EMPLOYER ____________________________________ Job Title_________________

If you have more than six employers, please attach a list.

MEDICAL PROBLEMS (Symptoms)

Symptoms and complaints:_____________________________________________________________

How long can you sit?__________________ Stand?______________________

If you have more doctors, please attach list.

MENTAL OR PSYCHIATRIC TREATMENT, COUNSELING

Psych Doctor's Name /Psych Clinic:______________________________________________________

Psych Doctor's Name /Psych Clinic:______________________________________________________

If you have more doctors, please attach a list.

HOSPITAL ADMISSIONS OR ER VISITS/SURGERIES

If you have additional hospital visits, please attach list.

DRUG/DOSAGE REASON/CONDITION DOCTOR HOW LONG SIDE EFFECTS

1._____________ __________________ _______________ __________ __________________

2._____________ __________________ _______________ __________ __________________

3._____________ __________________ _______________ __________ __________________

4._____________ __________________ _______________ __________ __________________

5._____________ __________________ _______________ __________ __________________

6._____________ __________________ _______________ __________ __________________

7._____________ __________________ _______________ __________ __________________

8._____________ __________________ _______________ __________ __________________

9._____________ __________________ _______________ __________ __________________

10._____________ __________________ _______________ __________ __________________

11._____________ __________________ _______________ __________ __________________

12._____________ __________________ _______________ __________ __________________

Nervous _____________ ____________ _______________ _________ __________

Any alcohol/drug related arrests? _____ Yes _____ No

Describe sleeping habits and change since disability began: ___________________________________

Are you presently able to:

YES NO Limitations/How Often

Grocery Shopping _____ _____ ____________________________

1. Relative/Friends Name: ____________________________________________________

2. Relative/Friends Name: ____________________________________________________

3. Relative/Friends Name: ____________________________________________________

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THE ENCLOSED QUESTIONNAIRE MAY TAKE SEVERAL HOURS TO COMPLETE.

DATE: _ Referred by: _ Friend/Client Name

Name:_________________________________ Social Security Number: _/_/_____

Spouse’s Name: ________________ Spouse’s SSN //

Social Security $ $___

Do you have a claim for Worker's Compensation? Yes No

Benefit Amount $____________ Weekly _Bi-weekly ___ Monthly W/C

(1) LAST EMPLOYER ____________________ Job Title_

(2) LAST EMPLOYER ____________________ Job Title_

How long can you sit? Stand?____

1.___ _ ______________

2.___ _ ______________

3.___ _ ______________

4.___ _ ______________

5.___ _ ______________

6.___ _ ______________

7.___ _ ______________

8.___ _ ______________

9.___ _ ______________

10.___ _ ______________

11.___ _ ______________

12.___ _ ______________

Nervous ___ _ _ ______

Any alcohol/drug related arrests? _ Yes _ No

Grocery Shopping ___ _ __________________________