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STATE OF HAWAII Med-QUEST Division
Department of Human Services
DHS 1127 (Rev. Interim 03/14)
MEDICAL HISTORY AND DISABILITY STATEMENT
Instructions: It is very important that you read and answer all questions carefully. Your responses may
help to determine if you are disabled. You may ask someone such as a relative, friend, eligibility worker,
or someone from the health care field to help you complete this form. If someone helps you to complete
the form, the answers should, to the extent possible, be in your own words.
Name of potentially disabled individual:
Last Name First Name
Beneficiary ID Number: _____________________________ Case Number: ______________________
SOCIAL SECURITY DISABILITY INSURANCE (SSDI) INFORMATION
1. Are you receiving SSDI? [ ] Yes [ ] No
2. Have you ever received SSDI? [ ] Yes [ ] No
3. If yes to #2, why did the SSDI stop? __________________________________________________
________________________________________________________________________________
4. Have you applied for social security benefits for your current disability? Check appropriate block(s):
[ ] No
[ ] Yes. Date applied for benefits: __________________________________________________
[ ] My application is pending.
[ ] My application has been approved and I am currently or will soon be receiving benefits.
[ ] My application was denied. Explain reason given for denial of benefits:
MEDICAL PROFILE
1. Describe your disability and explain the reason(s) why you are unable to work:
2. Describe the cause of your disability (i.e. accident, injury, illness, etc):
3. Describe all treatment(s) prescribed by any physician for your disability:
4. How often do you see your doctor for treatment? (Check one of the following blocks)
[ ] weekly [ ] several times a month [ ] monthly [ ] quarterly or more
5. List hospitalization(s) within the past two years, reason for hospitalization(s), and duration(s) of stay:
Medical History and Disability Statement
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