Has your initial application been rejected by the Social Security Administration?

Yes
No
Haven't file yet

-- If yes, have you as yet filed an appeal of that denial?

Yes
No

When were you last employed and in what capacity?

What type of injury or impairment do you currently experience?

Are you currently treating with a doctor?

Yes
No

-- If so, what kind of doctor?

What type of medication has your doctor presribed?

In your own words, why do you feel you cannot return to work?