SSDI/SSI Medical Opinion Request

Thank you for your interest in David Medical Services.

We provide independent, evidence-based physician medical opinions for individuals seeking Social Security Disability Insurance (SSDI) or disability-based Supplemental Security Income (SSI) benefits. Our medical opinions evaluate diagnosed conditions, supporting medical evidence, and the functional limitations that may affect an individual's ability to work.

Please complete this form so our physicians can better understand your medical circumstances, claim status, and documentation needs.

Important: We provide independent medical evaluations and opinions, not legal representation or assistance with filing Social Security disability applications. Submission of this form does not establish a physician-patient relationship or guarantee that a favorable medical opinion can be provided.

Who is completing this form?* This field is required.

Employee

Attorney or representative

Family member or caregiver

Other

Applicant's full legal name* This field is required.

First name

Last name

Date of Birth* This field is required.

Date

Email address* This field is required.

example@example.com

Phone number* This field is required.

Please enter a valid phone number.

State of residence * This field is required.

If outside the US, provide city and country

Preferred method of contact

Phone

Either method is fine

Which type of Social Security disability benefit are you seeking?* This field is required.

Social Security Disability Insurance (SSDI)

Supplemental Security Income (SSI)

Both SSDI and SSI

Not sure

What is the current status of your disability claim?* This field is required.

Preparing to apply

Initial application pending

Initial application denied

Reconsideration pending

Reconsideration denied

Administrative Law Judge hearing requested

Hearing scheduled

Appeals Council review

Federal court appeal

Other

Have you received a denial or unfavorable decision?* This field is required.

Yes

Please briefly explain the reasons given for the denial, if known.

0/100

Are you currently represented by an attorney or disability advocate?* This field is required.

Yes

Please provide the representative's name and contact information.

Is there an upcoming deadline or scheduled hearing?* This field is required.

Yes

Not sure

Please provide the date and explain the deadline or hearing.

0/100

What medical conditions are contributing to your inability to work?* This field is required.Please list the physical and/or mental health conditions that you believe interfere with your ability to work. Include approximate diagnosis dates, if known.

0/100

Which condition or combination of conditions most significantly limits your ability to work?* This field is required.

0/100

Approximately when did your medical conditions begin affecting your ability to work?

Are you currently receiving medical treatment for these conditions?

Yes

For some conditions

Please describe your current treatment.Include relevant medications, specialist care, physical therapy, procedures, or other treatments.

0/100

Have you experienced medication side effects that affect your ability to function or work?

Yes

Please describe the side effects and their impact.

0/100

Have your treating medical providers discussed work restrictions or limitations with you?

Yes

Not sure

Please describe these restrictions or limitations.

0/100

Which of these PHYSICAL activities are affected by your medical conditions?* This field is required.

Sitting for prolonged periods

Standing

Walking

Lifting or carrying objects

Reaching or using arms

Handling objects or using hands

Bending, kneeling, or climbing

Maintaining balance

Other physical limitations

None / not applicable

Which of these COGNITIVE or MENTAL activities are affected by your medical conditions?* This field is required.

Concentrating or maintaining attention

Remembering instructions or information

Completing tasks

Managing stress

Interacting with others

Maintaining a consistent work pace

Adapting to changes or new tasks

Other cognitive or mental limitations

None / not applicable

Additional activity limitations not listed previously?* This field is required.

Persistent pain

Fatigue or reduced endurance

Shortness of breath

Need for frequent rest periods

Frequent medical appointments or treatments

Unpredictable symptoms or flare-ups

Medication side effects

None / not applicable

Other

Below, describe how your medical conditions affect your ability to perform the activities on a typical workday?* This field is required.For example, describe your difficulties with walking, standing, sitting, concentrating, completing tasks, or maintaining activity throughout the day.

0/100

Do your symptoms fluctuate or occur in episodes?* This field is required.

Yes

No, symptoms are relatively consistent

Not sure

How frequently do these symptom episodes occur, and how long do they typically last?* This field is required.

0/100

Do your medical conditions require you to rest, lie down, or take unscheduled breaks during the day?* This field is required.

Yes

Please describe how often you have to rest, lie down, or take unscheduled breaks, and for approximately how long.* This field is required.

0/100

How long have these functional limitations been present?* This field is required.

Less than 3 months

3-6 months

6-12 months

More than 12 months

Varies by condition

Do you expect these limitations to continue for at least 12 months?* This field is required.

Yes

Not sure

Are you currently working?* This field is required.

Working full-time

Working part-time

Not currently working

On medical leave

Other

What is your current occupation or job title?* This field is required.

What was your most recent occupation or job title, and when did you last work?* This field is required.

Why did you stop working or reduce your work hours?* This field is required.

0/100

Please describe the primary duties or your most recent job, or your current job if you are still working.* This field is required.Briefly describe the physical, mental, and other important demands of your job.

0/100

Have you attempted to return to work or continue working despite your medical limitations?* This field is required.

Yes

What difficulties did you experience?* This field is required.

0/100

What aspects of working do you believe would be most difficult because of your medical conditions?* This field is required.

0/100

What type of medical documentation are you seeking?* This field is required.Check all that apply.

Medical opinion describing my medical conditions and functional limitations

Medical opinion addressing my ability to perform work-related activities

Medical opinion addressing concerns raised in a prior SSA denial

Physician completion of a functional capacity questionnaire or other form

I'm not sure. I would appreciate guidance.

Who recommended or requested that you obtain an independent medical opinion?* This field is required.

Attorney or disability representative

Treating physician

Social Security Administration

Family member or caregiver

My own decision

Other

What medical records do you currently have available?* This field is required.Select all that apply.

Primary care records

Specialist consultation records

Hospital or emergency department records

Imaging or diagnostic test results

Laboratory results

Mental health treatment records

Previous functional capacity evaluations

Prior SSA decisions or medical assessments

Other

Approximately how many pages of medical documentation do you anticipate submitting?* This field is required.

25 pages or less

26 to 50 pages

51 to 100 pages

101 to 200 pages

More than 200 pages

Not sure yet

Other

Is there anything else you would like our physicians to understand about your medical circumstances or request?

0/100

Please review and acknowledge the each of the following:* This field is required.

I understand that David Medical Services provides independent, evidence-based physician medical opinions. A favorable opinion is not guaranteed, and all medical conclusions must be supported by the available evidence.

I understand that submission of this intake form does not establish a physician-patient relationship or constitute an agreement to provide services.

I understand that David Medical Services does not provide legal representation, determine eligibility for Social Security disability benefits, or guarantee approval of a disability claim.

I understand that fees, records requirements, and the scope of any medical opinion will be communicated before services begin.

Please verify that you are human* This field is required.

SSDI/SSI Medical Opinion Request