Medical And Job Form Worksheet – Fill Out and Use This PDF

Updated: Nov 12, 2026

The Medical And Job Worksheet form is a crucial document for adults who are starting the application process for Social Security disability benefits. It helps organize medical conditions, job history, medications, medical visits, and more to streamline the process. Although it's not the application itself, it prepares applicants for a smoother appointment, whether online, in person, or by phone. Before applying for disability benefits, filling out this form could be your important first step. For more detailed assistance, consider clicking the button below to start filling out your form.

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How to Fill Out Form SSA-3381

Form SSA-3381 at a glance

What it is: Form SSA-3381 is the Medical and Job Worksheet - Adult.

A filled-in Form SSA-3381 example: a worker prepares for a disability appointment

Form SSA-3381 example filled out, example: a worker prepares for a disability appointment — A worker fills out the worksheet before a disability appointment. The worker lists one condition, gives height and weight, and one doctor with dates seen. The picture shows page 1 only, and its names and figures are sample values. Nothing goes in the other Medical Conditions lines because the worker has one condition. The other Medical Sources rows stay empty because the worker saw one doctor.

How to fill out Form SSA-3381, box by box

Medical Conditions

List all of the physical or mental conditions (including emotional or learning problems) that limit your ability to work, each condition separately. If you have cancer, include the stage and type.

Height and weight

Write your height without shoes in feet and inches and your weight without shoes in pounds.

Medical Sources

List any doctors, hospitals, clinics, therapists, or emergency rooms you have visited because of your conditions.

For each, write the Name, Address, Phone Number (with area code), Date First Seen or Admission Date and Date Last Seen or Discharge Date.

More rules for Form SSA-3381

If you are not working, write when you stop working.

Bring this worksheet to your appointment or have it with you if your appointment is by telephone.

List any medicines you take and why you take them; if prescribed, provide the doctor's name.

For each medicine, write the Name of Medicine, Why You Take It and Prescribed By.

List any medical tests you had or are going to have in the future.

For each test, write the Name of Test, Provider Who Sent You and Date(s).

List the jobs (up to 5) that you have had in the 15 years before you became unable to work because of your physical or mental conditions, your most recent job first.

For each job, write the Job Title (e.g., cook), Type of Business (e.g., restaurant), Dates Worked From Mo/Yr To Mo/Yr, Hours per Day, Days per Week and Rate of Pay Amount Frequency.

Do not delay filing your application, even if you do not have all of the information.

Common questions about Form SSA-3381

When is this form not the right one?

Please do not mail this worksheet to your local office. Complete this worksheet to get ready for the appointment or when filing online. This worksheet is not the application for Social Security disability benefits. You should bring this worksheet to your appointment or have it with you if your appointment is by telephone.

Sources

[1] Form SSA-3381 (12-2009), Medical and Job Worksheet - Adult, Social Security Administration (the Official source link on this page).

Medical And Job Form Worksheet PDF Details

Navigating the process of applying for Social Security disability benefits can be complex and requires careful preparation. The Medical and Job Worksheet - Adult, a critical tool in this process, is designed to help applicants compile and organize important information needed for their disability claim. While it is not the application itself, this worksheet serves as a comprehensive guide to prepare for either an in-person or telephone appointment, or when filing a claim online through the Social Security Administration's website. Applicants are advised against mailing this worksheet to their local office but are encouraged to start the application process online for efficiency. The worksheet comprises several sections including medical conditions detailing any physical, mental, emotional, or learning problems; employment history focusing on jobs held in the 15 years prior to the onset of disability; medical sources such as doctors and hospitals visited; medications prescribed, including the prescribing doctor; and any medical tests conducted or planned. Completing this worksheet is a crucial step in ensuring all relevant information is ready and available, helping to streamline the disability benefits application process. Importantly, applicants are reminded to proceed with filing their application even if they don't have all the information immediately at hand, as the Social Security Administration can assist in gathering any missing details.

Question	Answer
Form Name	Medical And Job Form Worksheet
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	ssa 3381, form 3381, ssa 3381 fillable form, medical and job worksheet