Ldss 1151 Form

01 this form. I. HAVE YOU BEEN TREATED BY ANY OTHER DOCTORS FOR YOUR IMPAIRMENTS 7. HAVE YOU BEEN HOSPITALIZED NAME OF HOSPITAL PATIENT OR TREATED DNo If YES. LDSS-1151. LOSS-1151 AGENCY Rev* 8/9B DISABILITY INTERVIEW NEW YORK STATE DEPARTMENT B SOCIAL SECURITY A NAME Last. First. Middle E SSIISSD DISABILITY HISTORY Indude OF HEALTH NUMBER C. DATE OF BIRTH 0 TELEPHONE F CASE NUMBER Dates J* CATEGORY IIMPAIRMENTS AT REFERRAL c FNP MEDICAID PUBLIC ASSISTANCE MEDICAID ONLY FS ONLY o OTHER K. AUDIT CASE DYES PART I-INFORMATION 1. WHEN DID YOUR IMPAIRMENTS YOU MONTH DAY 2 DID YOU WORK AFTER THE DATE SHOWN IN FIRST BOTHER n YEAR OF THE PRIMARY NAME Please explain 4. LIST THE NAME* ADDRESS AND TELEPHONE NUMBER MEDICAL RECORDS ABOUT YOUR IMPAIRMENTS* ABOUT YOUR MEDICAL RECORDS PHYSICIAN I WHO HAS IF YOU HAVE NO DOCTOR CHECK ADDRESS 3. A DID YOUR IMPAIRMENTS FINALLY CAUSE YOU TO STOP WORKING IF SO. WHEN ITEM 1 3 B DOES YOUR HEALTH AFFECT YOUR ABILITY TO WORK 0 NO ABOUT YOUR IMPAIRMENTS HOW OFTEN DO YOU SEE THIS DOCTOR REASONS Include Area Code. DATE YOU FIRST SAW THIS DOCTOR* FOR VISITS State illness or injury for which you had an examination tt. / DATE YOU LAST SAW THIS DOCTOR* or treatment. TYPE OF TREATMENT OR MEDICINES RECEIVED Such as surgery. chemotherapy or injury. If no treatment or medicines. indicate NONE. radiation* and he medicines including strength and dosage taken for your iftness Rev 81911 5. HAVE YOU SEEN ANY OTHER DOCTORS FOR YOUR IMPAIRMENTS DNO AND TREATMENT If different thin in. on the front. 1 Sheet AT A CLINIC FOR YOUR IMPAIRMENTS - Continuation OR CLINIC OR CLINIC NUMBER CONTACT POSmON PERSON VllERE YOU AN INPATIENT Stayed It Ielst overnight VllERE YOU AN OUTPATIENT FOR HOSPITALIZATION Q NO NO If YES* indicate IdmiSSion II. HAVE YOU BEEN TREATED BY ANY OTHER HOSPITALS OR CLINICS FOR YOUR IMPAIRMENTS YOU HAD ANY OF THE FOLLOWING Ind discharge dates. OR CLINIC VISITS State illness or injury for whidl complete you had an examination ONO induding strength and dosage taken for your illness or CHECK APPROPRIATE TEST TESTS IN THE LAST YEAR BLOCK OR BLOCKS Electrocardiogram Breathing Tests Blood Te5ts WHEN DONE DONE Chest X-Ray IF YES SHOW WHERE Other X-Ray Other Name body part here Specify 10. HAVE YOU BEEN SEEN BY OTHER AGENCIES FOR YOUR DISABLING riA. WorIler I Compensation Vocationll RehlbiIitlItion* eIIC. NAME Of AGENCY YOUR CLAIM NUMBER DATES Of VISITS POSITlON -2- PART 111-INFORMAnON ABOUT YOUR ACnVITIES. HAS YOUR DOCTOR TOLD YOU TO CUT BACK OR LIMIT YOUR ACTIVITIES IF YES GIVE THE NAME OF THE DOCTOR 12. DESCRIBE YOUR DAILY ACTIVITIES Household Chores IN ANY WAY BELOW AND TELL WHAT HE OR SHE TOLD YOU ABOUT CUTTING IN THE FOLLOWING Recreational NO BACK OR LlMmNG ACTIVITIES* AREAS AND STATE WHAT AND HOW MUCH YOU DO OF EACH AND HOW OFTEN YOU DO IT activities and hobbies Social contacts any similar 13. SCHOOLING Elementary OH. S* Speak DRead 18. PROFESSIONAL College 18. ENGLISH OR VOCATIONAL TRAINING 14. HIGHEST GRADE COMPLETED Special Class or School OTHER LANGUAGE S Write / 5. AGE AT COMPLETION Specify course of study.