Disability Questionnaire Don Pilzer Attorneys Greenville South Carolina

Name:
Address:
City:
State:
Zip:
Phone Number:
E-mail address:
Gender:	Male Female
Age:
Have you previously applied for benefits?	Yes No
Date applied for benefits:
Date case denied, if known:
Date Disability Began:
List your medical conditions: (i.e. cancer, heart disease, arthritis, etc.)
Number Of Hospitalizations:
Briefly describe how your impairments prevent you from working:
Do you have problems walking?	Yes No
Do you have hand limitations?	Yes No
Do you have problems sitting or standing?	Yes No
Do you have severe pain?	Yes No
Highest level of education:
Your last job title:
Are you currently working?	Yes No
Date employment ended:

NOTE: The use of the Internet for communications with the firm will not establish an attorney-client relationship and messages containing confidential or time-sensitive information should not be sent.

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation. From our offices in Greenville, we represent clients seeking Social Security benefits throughout Greenville, Oconee, Pickens, Anderson, Spartanburg, and Union counties in upstate South Carolina, including the communities of Pickens, Anderson, Spartanburg, Union, Taylors, Greer, Easley, Mauldin, Simpsonville, and Seneca. We also accept claims in Laurens, Greenwood, and Abbeville counties.

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Disability Questionnaire for SC, GA, NC Residents Only