WORK INCENTIVE INITIATIVE
Full Employment Council
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Note: This disability assessment questionnaire will be used by the Full Employment Council to assess your health status and to evaluate the need for specialized services
Last Name First Name MI
PART II. HISTORY OF MEDICAL TREATMENT: If you have received treatment for any of the following, please check the appropriate box
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q NEUROLOGICAL: Frequent headaches, dizziness, stroke, epilepsy, and seizure disorder
q NEURPSYCHOLOGICAL: Have you ever had a head injury or concussion?
q ENT: Eyes, Ears, Nose, Throat
q CARDIOVASCULAR: Heart, Blood Vessels, Rheumatic Fever, Murmur, Palpitation, Chest Pains, High Blood Pressure
q RESPIRATORY: Breathing, chest/Lungs, Chronic Cough, Shortness of Breath, Emphysema,
q ORTHOPEDIC: Neuritis, arthritis, Gout, any Disorder of the Muscles, Bones, or joints
q INTERNAL: Stomach, Chronic Indigestion, Ulcers, Colitis, Gall Bladder, Liver, Kidney, Bladder, Prostate,
q ONCOLOGY: Cancer, Tumor, Cysts, or any other disorder of the skin or lymph glands
q PSYCHIATRIC: Depression or other emotional Disorder
q INFECTIOUS DISEASES: Hepatitis, Tuberculosis, HIV/AIDS
q SUBSTANCE ABUSE: Alcoholism, Drugs
q OTHER: Have you been treated for any other medical condition not noted above
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Questionnaire (Page 2)
PART III. EDUCATIONAL IMPEDIMENTS: If any of the following statements apply to you, please check appropriate box.
_____ _ I have difficulty with reading, math and following instructions
______ I have difficulty writing my thoughts down on paper and completing forms
(PLEASE PROVIDE THE NAME, ADDRESS AND DATE OF LAST SCHOOL ATTENDED)
Name:___________
Date Attended:_________________
Address: ________________________________________
________________________________________
Phone: ___________________________
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PART IV. SOURCE OF
MEDICAL TREATMENT: Please list the
source(s) of your last medical treatment.
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PHYSICIAN (S)
Name of Doctor: Last Date of Treatment:
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Address: Phone ( )
Name: Last Date of Treatment:
Address: Phone ( )
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