Medical and Job Worksheet (And How To Complete It)
You can use the Medical And Job Worksheet form to prepare information needed for filing. It will not be included with your claim.
You can download a copy of the worksheet at www.socialsecurity.gov/forms/ssa-3381.pdf
When completing the form:
Question A: Medical Conditions:
- List all of your health conditions by diagnosis, all injuries, and all conditions and symptoms. Do not try to judge what does and does not affect your work. Include old ailments that may still affect you, such as a bad back. Include symptoms or impairments that you may consider to be embarrassing. For example, some people don't list an inability to control bowels or urine, yet those very symptoms could be very important to help explain why you can't work.
- While any single condition may not be disabling, the combination of conditions can qualify you for SSDI benefits by limiting your ability to work.
- The health conditions do not have to be work related conditions.
- Keep in mind that these illnesses may be mental/emotional as well as physical, including the nervous system. If you have not already considered it, think about whether you are experiencing anxiety and/or depression. Anxiety and depression are likely to accompany not being able to work because of a health condition. Even if the condition on its own is not enough to obtain a disability determination, it may be a contributing factor that together with your physical health condition(s) allows you to be considered to be "disabled" for SSDI purposes.
- Include health conditions for which you have not seen a medical professional. NOTE: If mental or nervous symptoms are included as reasons you cannot work, a therapist or other practitioner who is treating you should be listed in Section 4. Social Security tends not to give much credence to untreated depression and other mental symptoms.
- Do not exclude current health conditions because they do not seem relevant to your ability to work.
- Side effects of medications should be treated as symptoms and listed if they are a factor limiting your ability to work.
- Use your own words if you do not know the medical name.
- Alcohol and drug abuse are not symptoms and cannot be used to determine if you are disabled for Social Security purposes. However, any physical or mental problems you suffer as the result of past abuse can be usable symptoms. For example, current addiction to cocaine will not be considered in determining whether you are disabled. However, cirrhosis of the liver due to past alcoholism will be considered.
- If you have not been keeping a health journal, consider starting one. In addition to being helpful with Social Security, it is likely to improve your relationship with your health care provider.
Question D: Medical Sources: Include:
- All mainstream hospitals, clinics, emergency rooms, walk in medical clinics, managed care facilities doctors and other people who have treated your condition(s)
- Mental, physical, occupational or other rehabilitative therapists
- Complementary or alternative doctors or practitioners
Question E: Medicines
- Attach your list of medications if you have one. If you don't have such a list, this is a good time to make one that you can keep with you at all times. A List of Medications comes in handy for doctor visits and emergencies. .
- Include dosage and frequency of each medication.
- Make a note explaining why you take each medication. If you don't recall why you take a particular drug, ask your doctor or his/her staff.
Question G: Job History
- Note that the question does not ask for each job you had in the last 15 years. It only asks about different "kinds of work."
- Do not skip any jobs you held during this period of time either for your current or former employers.
- If you have had a lot of jobs and cannot recall them all, do your best. The key is for the examiner to be able to determine vocational factors, such as your skills, and physical and mental abilities and experience.
- Keep in mind that Social Security has a copy of your earnings record. While teh record does not show what you did, it does show for whom you worked.