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NEW CLIENT APPLICATION - GRAMENOS LAW GROUP
"Where we put your BEST case forward"
Legal Name as it appears on Social Security card
*
First Name
Middle Name
Last Name
Have you ever filed SSD/SSI?
No, this is my first time/NEVER filed before
Yes, I was denied in past 60 days
Yes, I was denied over 1 year ago or more
Yes, I had a hearing and was denied
Yes, and case is pending
Yes, and I have an attorney on my case
Other
Whom can we thank for referring you to our office? (Attorney name/Law firm/Google/etc)
Age - presently
Current Height and Weight
Birth Date
*
Please select a month
January
February
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Month
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Day
Please select a year
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Year
SSN - this will be your case number
Address - where you receive mail
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
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Area Code
Phone Number
Email Address
*
Description of disabilities or complaints (MENTAL and PHYSICAL):
Have you previously been treated for any of these conditions? If yes, by whom? (PCP, Surgeon, ER, etc)
Are your present problems due to ANY injury? if yes, please select from the list
Please Select
On the Job Injury, no claim pending
On the Job Injury, have an attorney
On the Job Injury, need an attorney
Not a job injury
Deteriorating Health Issues
Other, not accident related
Have you filed a Worker's Compensation claim wherein you've hired an attorney/law firm? If so, who represents you (name/address) in that claim and how much are you receiving in TTD weekly payments? When did payment start and/or stop?
*
Are you UNABLE to work full time due to your condition(s)? (8 hours a day/5 days per week is full time)
Please Select
Yes
No
If so, since when (closest date as you can recall)?
Smoking, # of packs per day
Alcohol, # of drinks per week
LAST job you held (Job Title and Company):
When were you HIRED at your last job? (month/year)
On what date did your LAST job end (month/day/year; as close as you can recall)? If still employed by a company, but on short term or long term leave, when was the date you last PHYSICALLY reported to your job?
Did you miss any work as a result of the disability PRIOR TO this job ending? If so, how many days per month on average?
Why did this job end? (fired, quit, performance issues such as absences)
How many hours can you SIT in a day?
How many hours can you STAND/WALK in a day?
How much can you LIFT and CARRY (describe in detail)
Please indicate below, any surgery dates for the follow conditions (write "none" if not applicable):
Hernia
Cancer Related Surgeries
Thyroid
Stomach
Joint Replacement (indicate which joints if multiple)
Heart/Cardiac
Have you ever had any spinal procedures/spinal injections (be detailed below)?
WOMEN: Are you pregnant
Please Select
Yes
No
Not sure
Have you ever had Chiropractic care before?
Please Select
Yes, it helps
Yes, it didn't help
No, never
List any falls you've suffered related to your disabilities and the closest dates of each occurrence:
List any broken bones (fractures) or dislocations in past 2 years:
Who is your CURRENT primary care physician? NAME/ADDRESS/PHONE (you must be currently seeing a medical provider to support your disability case/filing)
*
What hospital/emergency room have you been to in the past 2 years? NAME/ADDRESS/PHONE
Who is your mental health provider/psychiatrist? NAME/ADDRESS/PHONE (leave blank if doesn't apply)
Where did you go for your physical therapy care in the past 2 years? NAME/ADDRESS/PHONE
Who did you got to for any surgeries in the past 2 years? NAME/ADDRESS/PHONE/DATES OF SURGERIES AND TYPES OF SURGERIES.
Are you taking any medications (prescriptions and/or over-the-counter)? If so, what are you taking (names, dosages, doctor that prescribed)?
Why can't you work a full time job any longer (provide details about physical and/or mental limitations)?
*
Marital Status
Married
Single
Divorced
What is your GROSS monthly household income presently? (all sources including spouses wages, child support, retirement, pension etc) Please use details in explanation.
Do you have any children under the age of 18? (name, age, DOB)
Do you have Medical Insurance?
*
Yes, Medicaid/State
Yes, through Spouse
Yes, private/COBRA/other
No, I was denied
No, I need to file for Medicaid
VA Insurance
Do you receive Food Stamps or SNAP food benefits through the State? (if Gross Household Income is more than $1500 a month, likely will not qualify)
*
Yes
No, I need to file
No, I was denied
No, don't qualify
How much are your Food Stamps/SNAP benefits per month?
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AM/PM Option
Mother's Maiden Name for security in file
City and State of birth for security in file
Highest level of education COMPLETED (ex: 11th grade, some college, college degree)
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