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GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HUMAN SERVICES
SOCIAL INFORMATION: MEDICAL REVIEW
NAME: .................................................................... PHONE: ..................... ................... BIRTHDATE: .........................................
PART A: (To be completed by customer or a representative) Today’s Date: ........................................... 1. Your usual job: ........................................................................................................... 2. Highest grade you completed in school: .................. If you have any special training or skills please give a descript ion: .................
......................................................................................................................... Are you currently in a training program? .........................
Are you interested in training? ................. Why? ......................................................................................................................................
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3. Why do you feel you are unable to work? (Customer’s statement of illness; how it affects ability to work.) .......................................
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4. HOW HAVE YOU MANAGED UP TO NOW (Include past periods getting TANF and also how you got by when unemployed.)
Type of work (starting with your last job) Describe the duties and activities of the job DATES From To Why did you leave this job?
5. YOUR CURRENT MEDICAL TREATMENT
What health problem? What doctor, clinic or hospital Last Appointment/ Next Appt.
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6. IF YOU STAYED IN THE HOSPITAL
What was it for? (starting with your last stay) When was it?
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DHS – 854 (03/2014)