Disability Report - Appeal

Page 2
SECTION 3 – MEDICAL CONDITIONS
3. A. Since you last told us about your medical conditions, has there been any CHANGE (for better or worse)
in your physical or mental conditions?
Yes, approximate date change occurred: No
If yes, please describe in detail:
3. B. Since you last told us about your medical conditions, do you have any NEW physical or mental
conditions?
Yes, approximate date of new conditions: No
If yes, please describe in detail:
If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 4 – MEDICAL TREATMENT
4. A. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
Yes No
If yes, please list the other names used:
4. B. Since you last told us about your medical treatment, have you seen a doctor or other health care
provider, received treatment at a hospital or clinic, or do you have a future appointment scheduled?
Yes No (Go to SECTION 6 – MEDICINES)
4. C. What type(s) of condition(s) were you treated for, or will you be seen for?
Physical Mental (including emotional or learning problems)
If you answered “Yes” to 4.B., please tell us who may have NEW medical records about any of your physical or
mental conditions (including emotional or learning problems).
Use the following pages to provide information for up to three (3) providers. Complete one page for each
provider. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page.
Please include:
doctors' offices
hospitals (including emergency room visits)
clinics
mental health center
other health care facilities.
Only list the providers you have seen since you last told us about your medical treatment.
Form SSA-3441-BK (03-2015) ef (03-2015)
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