Have you worked full-time for 5 out of the last 10 years?

Yes

No

Is an attorney already helping with your case?

Yes

No

Do you currently earn less than $1,000 per month?

Yes

No

Are you currently seeing a doctor or taking any prescription medication?

Yes

No

Are you already receiving any Social Security Disability benefits?

Yes

No

Are you a veteran?

Yes

No