Client Interview Form

Sample Client Interview Form

Disability Associates Logo

Name: ______________________________	Date: _________	Time:_______
Address: ______________________________	SSN: __________________	Phone: _______________________
DOB: ____________	Age: ____________	Married __ Single __ Widow __ Divorced
Spouse: __________________________	Years Married: ___________
Type of Claim: SSI _______ SSDI _______ ALJ _______

Application/Termination

Reconsideration

Hearing Request

Application Date:

Recon. Request Date:

__ Not yet filed

Denial/Term. Date:

Recon. Denial Date:

Date filed:

Rationale:

Timely: __ Yes __ No

Why not?

PRESENT SYMPTOMS

	SYMPTOM 1	SYMPTOM 2	SYMPTOM 3	SYMPTOM 4
Location:
Description: (consider describing occasional radiation of pain as a separate symptom)
Frequency:
Duration:
What starts it?
What aggravates it?
Intensity at its worst 1 - 10:
Usual intensity 1 - 10:
Intensity at its best 1 - 10:
What makes it better?
Effectiveness of medication:
Side effects of medication:

How often do you have any of the following?

Nausea:		Crying spells:
Fainting:		Headaches:
Dizziness:		Spasms:
Bladder control problems:		Cramps:
Seizures:		Diarrhea:
Dates of most recent seizures:

Have you had any of the following tests recently?

Medical Testing	Location	Approx Date
Treadmill Stress Test
Other Heart Tests Identify:
EMG/Electro diagnostic Studies
X-ray/CAT Scan Part of Body:
MRI Part of Body:
Myelogram:
Breathing Tests:
MMPI
Other:

FAMILY, HOUSING AND INCOME:

List all children who were under 18 (or under 19 and still in high school or disabled adult children)
at any time after the alleged onset date. Identify custodian.

CHILDREN'S NAMES	RELATIONSHIP	DOB	CUSTODIAN

Current Household Income and Employment

Monthly Income:	CLAIMANT	SPOUSE
*Employment after onset from to
*Unemployment compensation after onset from to
V.A. benefits: Type: Service connected; non-service connected:
Worker's Compensation after onset from to
Loans:
Investments:
Disability Insurance: (Enter name and address of LTD carrier on Analysis form.)
Pension Benefits (company):
SSI (Especially Spouse SSI):
Social Security Disability/ Retirement:
Total Income:

*Identify these as issues on Analysis form.

Place of birth: _______________________

U.S. citizen. ____

Immigration Status: ______________________

Describe your average daily activities:

Describe: ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Environmental Restrictions

ENVIRONMENTAL RESTRICTIONS:	NO RESTRICTION	AVOID CONCENTRATED EXPOSURE	AVOID EVEN MODERATE EXPOSURE	AVOID ALL EXPOSURE
Extreme cold
Extreme heat
Wetness
High humidity
Noise
Chemicals
Solvents/cleaners
Soldering fluxes
Cigarette smoke
Perfumes
Fumes, odors, dusts, gases
List other irritants or allergens:





Hazards (machinery, heights, etc.)

Describe how these environmental factors impair activities
and identify hazards to be avoided.

____________________________________________________________________________________

MENTAL RESIDUAL FUNCTIONAL CAPACITY

I.	I. MENTAL ABILITIES AND APTITUDES NEEDED TO DO UNSKILLED WORK	Unlimited or Very Good	Limited but satis-factory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
	Remember work-like procedures
	Understand and remember very short and simple instructions
	Carry out very short and simple instructions
	Maintain attention for two hour segment
	Maintain regular attendance and be punctual within customary, usually strict tolerances
	Sustain an ordinary routine without special supervision
	Work in coordination with or proximity to others without being unduly distracted
	Make simple work-related decisions
	Complete a normal workday and workweek without interruptions from psychologically based symptoms
	Perform at a consistent pace without an unreasonable number and length of rest periods
	Ask simple questions or request assistance
	Accept instructions and respond appropriately to criticism from supervisors
	Get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes
	Respond appropriately to changes in a routine work setting
	Deal with normal work stress
	Be aware of normal hazards and take appropriate precautions

II.	II. MENTAL ABILITIES AND APTITUDES NEEDED TO DO SEMISKILLED AND SKILLED WORK	Unlimited or Very Good	Limited but satis- factory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
	Understand and remember detailed instructions
	Carry out detailed instructions
	Set realistic goals or make plans independently of others
	Deal with stress of semiskilled and skilled work

Explain limitations falling in the three most limited categories (identified by bold type):

___________________________________________________________________________________

If stress tolerance is an issue, what demands of work do you find stressful?

	__ speed	o	__ being criticized by supervisors
o	__ precision	o	__ simply knowing that work is supervised
o	__ complexity	o	__ getting to work regularly
o	__ deadlines	o	__ remaining at work for a full day
o	__ working within a schedule	o	__ fear of failure at work
o	__ making decisions	o	__ monotony of routine
o	__ exercising independent judgment	o	__ little latitude for decision-making
o	__ completing tasks	o	__ lack of collaboration on the job
o	__ working with other people	o	__ no opportunity for learning new things
o	__ dealing with the public (strangers)	o	__ underutilization of skills
	__ dealing with supervisors	o	__ lack of meaningfulness of work

CHECK ITEM TO INDICATE DIFFICULTY WAS OBSERVED

o	__ Reading	o	__ Hearing	o	__ Using Hands	o	__ Walking
o	__ Writing	o	__ Speaking	o	__ Breathing	o	__ Sitting
o	__ Answering	o	__ Understanding	o	__ Seeing	o	__ Rising

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