Debunking the Medical and Job Worksheet (Adult)

For individuals who are applying for Social Security Disability benefits, the SSA has created the Medical and Job Worksheet (Form SSA-3381) to help them prepare for their appointment or online application process.

The two-page worksheet offers space to fill out information in seven helpful categories as follows:


  • Medical Conditions: Space to list up to five relevant physical or mental conditions that limit your ability to work.
  • Work information: The date you stopped working, assuming you are currently unable to work.
  • Physical statistics: Your height and weight measurements to be taken without shoes.
  • Medical sources: Any healthcare practitioners’ offices, medical facilities, hospitals, clinics, therapy centers, emergency rooms or other treatment you have received for the disabling conditions listed in the first section.
  • Medications: The name of any medicines you are taking for your disabling condition(s), why you take them, and the names of the healthcare practitioners who ordered them if they are prescription medications.
  • Medical Tests: The names of any tests you’ve undergone for your listed disabling conditions, the healthcare providers who ordered the tests, and the dates you were tested.
  • Job History: Space for up to five most recent jobs you’ve held in the past 15 years before the onset of your disabling condition. You will need to provide the title of your position, the type of business/industry, start and completion dates, the frequency you worked this job and your pay rate for each job.


To view or print off the official form, you can click here. Please note that this is NOT the official application for benefits, but rather a resource to put helpful details in one place for easy reference.


As you fill out this form, remember that it’s helpful to start compiling official documents (particularly medical records) that support this information. Having as much concrete proof will greatly increase your chances for success.


An experienced West Virginia Social Security Disability Attorney can help you build a solid case from the start. The team at Jan Dils, Attorneys at Law, will draw from proven experience to help make the process as easy as possible. You can schedule a 100% complimentary first meeting by contacting us today.


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Jan Dils, Attorneys at Law

Jan Dils, Attorneys at Law