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Disability Application Questionnaire
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18
Questions
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HIPAA
Compliance
1
Name
First Name
Last Name
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2
Email
example@example.com
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3
What state were you born in?
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4
How many hours per week do you work in your primary occupation?
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5
What is your annual earned income from your primary occupation?
Current Year
Last Year
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6
Do you own any part of, or are you an independent contractor for the business where you work?
YES
NO
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7
If YES, please answer the following questions:
Please Select
C Corp
S Corp
LLC
LLP
Sole Proprietor
Partnership
Other
Please Select
Please Select
C Corp
S Corp
LLC
LLP
Sole Proprietor
Partnership
Other
Business Entity
Number of Employees: (Full Time/Part Time)
% of business entity owned
Total years owned
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8
What is your height and weight?
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9
In the last 5 years have you been treated for, or been diagnosed by a medical professional for any of the following: heart condition (heart attack, heart arrhythmia, valvular disease), back or neck disorder, anxiety or depression, cancer, diabetes or neurological disorders (such as stroke, epilepsy, carpal tunnel syndrome)?
YES
NO
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10
If YES, please provide details including dates, diagnoses and treatments; also include healthcare provider name(s) and address(es).
If NO, skip to the next slide.
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11
Do you use marijuana?
YES
NO
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12
If YES, provide frequency, type, and how long you've used marijuana.
If NO, skip to the next slide.
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13
Are you currently eligible for benefits under, or covered by or received Medicaid, Disability Income, Worker's Compensation, Social Security Disability or any Federal or State Disability Plan
YES
NO
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14
Are you currently taking any medications?
YES
NO
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15
If YES, list each medication and the dosage.
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16
Have you received inpatient or outpatient treatment at a hospital, surgical center for rehabilitation facility in the past five years?
YES
NO
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17
If YES, please provide the date and reason for each visit.
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18
Please verify that you are human
*
This field is required.
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