Dma 5009 Form – Fill Out and Use This PDF

STATE OF NORTH CAROLINA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

SOCIAL HISTORY SUMMARY FOR THE DISABLED

______________________County Department of Social Services		Date_______________
Claimant ____________________________________	SSN ___________________________
County Case # ________________________________	District # ________________________

Telephone # or a number you can be reached ________________________________________

Person Providing Information and Telephone # (if different from claimant)

_______________________________________________________________________________

Nature of Disability (based on claimant’s description or statement)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

I.Onset of Impairment

A.Date of illness or injury began_______________________________________________________________

B.Date claimant stopped work ________________________________________________________________

C.Date the illness or injury became disabling_____________________________________________________

D.If still working:

Name of Employer _______________________________________________________________________

Supervisor’s name and telephone #___________________________________________________________

Hours worked ___________________________________________________________________________

Gross earnings ____________ weekly __________ monthly ____________________________________

II.Claimant’s Description of Impairment

A. Indicate how the claimant describes the symptoms of the disability and how they affect his ability to work.

_____________________________________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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DMA-5009 (08-08)

B.Describe claimant’s daily activities and explain how the impairments affect him such as seeing, hearing, speaking, reading, walking, writing, standing, breathing, sitting, using hands, arms, and other joints. Describe how his impairments limit what he can do.

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C.Worker’s Observation of Difficulties

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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III.Vocational Information (include self employment)

A. Principal Job (job done the longest in 15 years prior to onset)

1. Job Title __________________________________________________ 4. Hrs. /day _____________

2.Industry ____________________________________________________ 5. Days/week __________

3.Beginning date ______________________________________________ 6. Rate of pay/average earnings

Ending date _____________________________________________ $________per ___________

Other Jobs – List of jobs done in last 15 years prior to alleged onset date. Give approximate dates of employment ( use additional sheet if necessary)

___________________________________________________________________________________

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___________________________________________________________________________________

___________________________________________________________________________________

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B.Education/Highest Grade Completed ______________________________________________________

High School Graduate?_________________________________________________________________

Name and address of school if known ____________________________________

Additional education _____ Type _______________ Is claimant currently attending school?________

Name of school and address if known ____________________________________

Can claimant read and write? ________________________________________________

DMA-5009 (08-08)

IV.	List all Medical Sources (physicians, hospitals, emergency facilities, health departments,
	therapists, nursing homes, clinics, mental health centers,) including names and dates seen in
	the last twelve months. Give hospital or clinic number, which is on hospital or clinic card or
	hospital bills. (Twelve months prior to and including application month, plus any future medical
	appointments)
	Medical Source	Condition Treated	Dates Seen at Dr.’s office,
	Name, Address, Ph. #	EKG, X-rays	clinic, hospital
	_______________________________________________________________________________________
	_______________________________________________________________________________________
	_______________________________________________________________________________________
	_______________________________________________________________________________________
	_______________________________________________________________________________________
	_______________________________________________________________________________________
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	Is claimant still being treated? Yes ____	No ____

V.VR Referral ___ Yes ___ No Date last seen ______________________

VR Office ___________________________________________________

Counselor’s Name ________________________Phone #______________

VI.	If a mental impairment is alleged, if there is evidence of drug or alcohol abuse or if the
	person is homeless, in a shelter or in a halfway house, please give name, address and phone
	number of someone who can be contacted as a third party.
	_________________________________________________________________________
	_________________________________________________________________________
	_________________________________________________________________________
	_________________________________________________________________________
	Signature ____________________________
	Title_________________________________
	Telephone # __________________________

DMA-5009 (08-08)