Social Security Disability Self-eValuation
What are my chances of getting
Social Security disability benefits?


1) Have your medical problems lasted more than 12 months, or are they expected to last more than 12 months?
a) Yes
b) No

2) Have your medical problems prevented you from working 8 hours a day, 5 days a week, 52 weeks a year, and will they last for at least a year?
a) Yes
b) No

3) If pain killing medications are prescribed what side effects do they have?
a) Dopey feeling
b) Drowsiness
c) Dizziness
d) Reduced alertness

4) How often do your symptoms plus the side effects of medications interfere with your ability to think and concentrate?
a) Never
b) Seldom
c) Frequently
d) Constantly

5) What is the average severity of your pain. (With 10 being most severe, meaning seeking medical help in an emergency room.)
a) 1,2,3
b) 4,5,6
c) 7,8,9
d) 10

6) If you were in a work situation, would you need to take unscheduled breaks?
a) Yes
b) No

7) If you would need to take unsceduled breaks in an 8 hour workday, how often would you need to take them?
a) Every half-hour or less
b) Between every half hour and one hour
c) Between every hour and every hour and one-half
d) Between every hour and one-half and two hours

8)If you would need to take breaks more often than every two hours, how long on average would each break need to be?
a) 5 minutes
b) More than 5 minutes
c) Between 5 minutes and 10 minutes
d) More than 10 minutes

9) Are you limited in the amount of repetitive reaching you can do?
a) Yes
b) No

10) What is your most comfortable position?
a) Sitting
b) Sitting in a reclining chair
c) Lying down

11) Are you limited in the use of your hands?
a) Yes
b) No

12) Are you chronically fatigued?
a) Yes
b) No

13) Would you require bedrest for any length of time beyond normal breaks?
a) Yes
b) No

If you are depressed, either because you're not able to physically function as you could in the past, or if depression, anxiety, personality disorders, or organic problems are the primary reason you're not able to work, a "no" answer to one or more of the questions between 14 and 25 should produce a favorable decision at the hearing level. However, it's critical to understand that your assertion that you possess any of these deficits in functioning will be discounted and ignored if they come from you. A treating psychiatrist or psychologist must attest to the prescence of these symptoms.


14) Are you able to remember, understand, and carry out simple one-step instructions?
a) Yes
b) No

15) Are you able to respond appropriately to supervision, coworkers, and usual work situations?
a) Yes
b) No

16) Are you able to deal with changes in the routine work setting?
a) Yes
b) No

17) Are you able to perform work activities within a schedule, maintain regular attendance, and be punctual within ordinary tolerances?
a) Yes
b) No

18) Are you able to sustain an ordinary routine without special supervision?
a) Yes
b) No

19) Are you able to work in coordination with or close proximity to others without being distracted by them?
a) Yes
b) No

20) Are you able to make simple work-related decisions?
a) Yes
b) No

21) Are you able to complete a normal workday and workweek without interruptions from psycholgically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods?
a) Yes
b) No

22) Are you able to ask simple questions or ask assistance?
a) Yes
b) No

23) Are you able to accept instructions and respond appropriately to criticism from supervisors?
a) Yes
b) No

24) Are you able to get along with coworkers or peers without distracting them or exhibiting behavioral extremes?
a) Yes
b) No

25) Are you able to be aware of normal hazards and take appropriate precautions?
a) Yes
b) No

26) Do you have memory loss?
a) Yes
b) No


©2006 Frederick A. Johnson, All rights reserved.

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