Social security disability questionnaire is a tool to verify the authenticity of an employee’s claim to social security disorder benefits. It is meant to test the gravity and genuineness of a claimant’s physical disability or impairment and evaluate whether it affects the individual’s job performance or not. It is therefore a platform to prove the intensity of one’s disability and render oneself eligible to reap the benefits for social security.

Sample Social Security Disability Questionnaire

Personal Information

Name of the claimant:



Job description:

Social security no.:

Respond to the Questionnaire Properly:

1)      What kind of disability do you suffer?

2)      When the disability was first diagnosed?

3)      Details of the diagnosis:

  • Name of the doctor referred:
  • Tests conducted to diagnose the impairment:
  • Name and address of the diagnosis center consulted:
  • Reports of the tests:
  • Medical facilities availed:

4)      Are you undergoing medical treatment for the said disability? If yes, mention details.

  • Name and details of the medical personnel supervising the treatment
  • Physiotherapy or other facilities utilized in treatment:
  • Tentative duration of the mentioned treatment:

5)      Are you currently under medication to heal the disability in concern? If so mention details.

  • Name of the doctor consulted:
  • Medicines prescribed:
  • Purpose:
  • Dosage:
  • Side effects (if any):

6)      How does the disability hamper your job activities?

7)      How does the impairment affect your professional relations?

8)      Does the disability affect your mental health?

9)      Do you feel discriminated against in your work place by virtue of your disability?