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Age of Applicant:*
What type of doctors are you currently seeing? List all.*
Do your doctors think you are disabled? If so, which ones*
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Are you currently collecting Social Security benefits?*
Have you applied for Social Security Disability benefits?*
if yes, what is the status?*
** If you applied, Please send us a copy of the decisions you have immediately to firstname.lastname@example.org
Approximate date last worked regularly / became disabled*
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Tell us about your disability.* (Maximum length: 500 characters.)
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