| Full name | … |
| Social Security Number | … |
| Date of birth | … |
| Phone | … |
| Mailing address | … |
(no conditions identified yet)
| Last job title | … |
| Last employer | … |
| Date stopped working | … |
| Highest pay (annual) | … |
| Physical demands | … |
(list each treating provider, reason, dates of treatment, phone)
(list each medicine, the condition it treats, prescriber, side effects)
(list each test, the date, where it was performed)
| Highest grade completed | … |
| School / training | … |
| Year completed | … |
| Special education? | … |
| Agency name | … |
| Contact | … |
| Services received | … |
…
This scaffold is not a filed claim. It is a preparation aid generated from your symptom entries. Bluebook is not affiliated with the SSA and provides no legal or medical advice. The official form is at https://www.ssa.gov/forms/ssa-3368.pdf.