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Law Office of
SUMMIT DISABILITY LAW
6009 SOUTH REDWOOD ROAD TAYLORSVILLE, UT 84123
Telephone: (801) 328-5600
INTAKE QUESTIONNAIRE

Welcome to our office. We would appreciate you taking a few moments and fill out this form. This will help us serve you better.

THIS IS A FREE CONSULTATION. We do not represent you until you have signed a retainer agreement and Appointment of Representative. In the event this law firm undertakes to represent you, all aspects of the representation including attorney fees and costs, will be discussed and agreed upon. We want to make sure that you understand all procedures and aspects of the case. We encourage you to ask questions. We also encourage you to divulge all information that you believe is necessary to assist the attorney in formulating an opinion. Please remember that the attorney is only rendering an opinion during this consultation. Anything he may say should not be construed as a guarantee of the case.

I UNDERSTAND THE CONDITIONS OF THE FREE CONSULTATION:
 
 
 
 
INITIAL QUESTIONNAIRE

Please take a moment and fill out this questionnaire as fully as possible. We understand that you may have good days and bad days. When filling this out, think of a typical average day.

 
 
Physical Residual Functional Capacity

(If your disability is not physical, please proceed to Psychological portion)

1. I can walk at a reasonable pace on a hard flat surface before stopping.
2. I can walk blocks at a reasonable pace on an uneven surface (like grass in a park) before stopping.
3. I can sit in a hard back chair (like a kitchen chair) for minutes at one time before I must get up and walk around.
4. I can stand in one place (like a grocery line) for minutes before I must sit down or walk it off.
5. I can sit, stand and walk (cumulatively and in any order) before I must lay down for minutes.
6. I must lay down during the day. Y N. If yes, how many times per day:
Duration of each rest period:
7. When I sit down, I must elevate my legs or have a special type of chair.
8. I can lift a gallon of milk comfortably from the floor to the waist.
9. I can lift a 12 pack of soda comfortably from shoulder level to chest level
10. I can climb a flight of stairs at a reasonable pace (12 steps)
11. When I climb or descend stairs I must:
a. Put both feet on the same step
b. Use the hand rail
c. Use the hand rail
12. I can do the following activities comfortably:
a. Bending
b. Kneeling
c. Crawling
d. Crouching
e. Stooping
f. Reaching
g. Grasping
h. Fine manipulation
13. When I climb or descend stairs I must:
Please describe any other assistive devices you use or any home modifications you have done to accommodate your disability:
PAIN
14. Are any of the following symptoms of pain present? Check all that apply:
Head Neck Mid-Back Low Back
Right Shoulder Right Arm Right Hand Left Shoulder
Left Arm Left Hand Right Hip Right Leg
Right Knee Right Ankle Right Foot Left Hip
Left Leg Left Knee Left Ankle Left Foot
15. Does the pain affect your ability to read.
16. Does the pain affect your ability to complete tasks.
17.Does the pain affect your speed in completing tasks.
18. Does your pain affect your relationship with spouse, kids, friends or family.
19. Are any of the following associated with your pain? Check all that apply:
Numbness Tingling (pins and needles Weakness
Increased sweating Muscle Spasm Skin Discoloration
Nausea Loss of Sleep Crying Spells
Loss of Concentration Depression Agitation
20. Please list all areas of pain. Be as specific as possible
a. Is pain:
b. How many hours per day do you have pain?
c. If you do not have pain every day, estimate how many hours of pain per week, or days per week or month:
d. Below is a list of activities. For each activity indicate how it affects your pain.
e. What other things relieve your pain?

Do you have any current problem with any of the following?
Shortness of breath Alcohol abuse
Coughing up blood High blood pressure
Hot/cold flashes Dizziness
Excessive sweating Swelling of feet/ankles
Heart palpitations Blackouts
Diarrhea Fatigue
Controlling your urine Difficulty sleeping
Vision Recent weight loss
Drug abuse Recent weight gain
Psychological

(If you suffer from pain or psychological disability, please fill out this portion)

Please assess your own Mental Abilities:

MENTAL ABILITIES AND APTITUDES NEEDED No Problem at all Some limits, but you can do it I can do it about 50% of the time I can do it only 33% of the time I can not do it at all
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
Work in coordination with or proximity to others without being unduly distracted
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
MENTAL ABILITIES AND APTITUDES NEEDED TO DO SEMISKILLED AND SKILLED No Problem at all Some limits, but you can do it I can do it about 50% of the time I can do it only 33% of the time I can not do it at all
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
Please fill out this portion
21. Do you drink any alcohol?
If yes, please answer the following questions:
a. What sort of alcoholic beverage do you usually drink? .
b. How much alcohol do you drink in a typical week? .
c. During the past month, was there any single day in which you had five or more drinks of beer, wine or liquor?
d. During the past six months, have you thought you should cut down on your drinking of alcohol?
e. During the past six months, has anyone complained about your drinking?
f. During the past six months, have you felt guilty or upset about your drinking?
g. As a result of alcohol use, have you ever lost a job?
h. As a result of alcohol use, have you ever lost a friend?
i. Have you had any problem with the law concerning your drinking?
j. Have you gone through any rehabilitation program for your drinking?
22. Do you take any type of street drug?
If yes, please answer the following questions:
a. What sort of drug do you usually take? .
b. How much of the drug do you take in a typical week? .
c. During the past six months, has anyone complained about your drug use?
d. As a result of alcohol use, have you ever lost a job?
e. As a result of alcohol use, have you ever lost a friend?
f. Have you had any problem with the law concerning your drug use?
g. Have you gone through any rehabilitation program for your drug use?
23. Have you ever been convicted of a felony?
  1. If yes, explain: .
57. Are you on probation or parole right now?
Wage Information:
a. What is the amount of your current income? $ per month.
b. What is the source of your current income? .
Living Information:
Where do you currently live?
Do you own or rent?
MEDICAL AND JOB WORKSHEET - ADULT

Help us to help you!

Completing this worksheet will help you get ready for the interview.

We may ask for additional information at the interview. If you need more space, use blank sheets of paper.

  1. Illnesses, injuries or conditions limiting your ability to work.
  2. Date you became unable to work because of your medical condition
  3. If applicable, Medical Assistance Number (Medicaid or other).
  4. Doctor/HMO/therapist/ or other person who treated your illnesses, injuries, or conditions, or who you expect to treat you in the future.
    NAME ADDRESS, ZIP CODE, and PHONE NUMBER PATIENT I.D. NUMBER DATE FIRST SEEN DATE LAST SEEN
  5. Hospitals, clinics, or emergency rooms you visited or expect to visit because of your illnesses, injuries, or conditions.
    NAME ADDRESS, ZIP CODE, and PHONE NUMBER PATIENT I.D. NUMBER DATE IN DATE OUT
    Form SSA-3381 (4-2005) Use prior editionsOVER
  6. Medications you take and why you take them. If prescribed, provide the doctor's name.
    NAME OF MEDICINE WHY YOU TAKE IT; PRESCRIBED BY
  7. Medical tests you had or are going to have in the future
  8. Jobs you had in the 15 years before you became unable to work because of your illnesses, injuries, or conditions.
    JOB TITLE
    (e.g., cook)
    TYPE OF BUSINESS
    (e.g., restaurant)
    DATES WORKED
    (month/year)     		HOURS PER DAY DAYS PER WEEK
    RATE OF PAY
    (per hour/ week/year)
NAME OF TEST
PLACE OF TEST
PERSON WHO SENT YOU;
DATE(S)
 
 
 
 
 
 
 
 
OUR LOCATION
 
 
SALT LAKE OFFICE
 
6007 South Redwood Road, Taylorsville, UT 84123
Phone: (801) 328-5600
 
 
 
 
 
 
 
SUMMIT DISABILITY LAW GROUP - CALL NOW FOR A FREE CONSULTATION