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Old us that he or she has a medical or psychiatric condition that will not allow him or her to work for at least 30 days. Your answers to the questions on this form will help us to determine the individual s employability status and/or disability status for our programs. If the patient is currently under your care, the report may be prepared from your existing records. Client Name: Social Security Number: Date of Birth: Client ID Number: Client s statement of his/her medical condition:.

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