MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION DISABILITY QUESTIONNAIRE	NAME	DCN	DATE
Dear Applicant, Please refer to the enclosed cover letter for instructions regarding this form. Do not return this form to your Family Support Division. We have sent you this form so that you can review the questions and make note of any items that you feel it is important for us to know about your medical condition. After you have sent in the rest of your paperwork, please call the Family Support Information Center toll free at 1-855-FSD-INFO (1-855-373-4636) and tell the Customer Service Representative that you need to speak with a MRT Specialist. You will be transferred to an MRT Specialist who will go over this form with you. If there are any questions on this form that you do not understand, the MRT Specialist will explain them to you at that time. Do NOT return this form.
1. Personal Information: Age Sex Height Weight
2. Highest Grade Completed: GED Yes No
3a. What physical symptoms/problems do you have?
3b. What mental health symptoms/problems do you have?
Do you have crying spells or depression because of your disability? Yes No How Often?
3c. Are your mental health symptoms due to your current circumstances (i.e. family, job, health)? Yes No
4. When did these symptoms/problems begin?
5. When did these symptoms first prevent you from working?
6. What are the limitations of your daily activities from this disability? Please list those you are unable to perform :
Able to perform?
Are you in need of caretaking? Yes No If yes, who provides? (Check one) Nurse Relative Neighbor Friend Other
7. Did you see a doctor or seek medical treatment for your symptoms? Yes No
Physician	How often?
Treatment received:
When?
Physician	How often?
Treatment received:
When?
8. Have you been given a specific diagnosis for your problem? Yes No What is the diagnosis?
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9. Have you gone to Vocational Rehabilitation? Yes No (If yes, obtain VR reports and any medical
examinations required by VR) What is the status of your Vocational Rehabilitation referral?
10. Have you applied for (Check if applicable) Social Security SSI VA ? Were you examined by a doctor for this application? Yes No (If yes, obtain medical reports from SSA)
What is the status of your application?
11. Did your problem require physical therapy? Yes No (Obtain medical information or reports) If yes, where? When?
Describe therapy
12. Describe any pain you have from these problems. (If specialized care was received for this pain, obtain medical reports)
13. List medications you take, prescribed or over-the-counter, side effects and how often medication is taken :
14. Who prescribed the medications? (Obtain medical information)
15. Have you been treated by or referred to a(n): YES NO REFERRED TREATED
Orthopedist
Internist
Neurologist
Cardiologist
Psychologist/Psychiatrist
Other Specialist
16. Have you been hospitalized due to your disability or illness? Yes No If yes, where?
How long? Dates?
Admitting physician name
ADDITIONAL INFORMATION AND COMMENTS
ITEM NO.
MO 886-2997 (7-14)/E 07-2014 IM-61B INFORMATIONAL