Form SSA-454-BK, Continuing Disability Review Report Instructions

Check this box if someone else, other than your medical providers, has your medical information or you are scheduled to see anyone else within the last 12 months.

Check this box if no one else, other than your medical providers, has your medical information or you are not scheduled to see anyone else within the last 12 months.

Check this box if you use an assistive device.

Check this box if you do not use an assistive device.

Enter the body part where the biopsy was performed, if known.

Enter the name of the healthcare provider or facility that scheduled or performed the biopsy.

Enter the name of the healthcare provider or facility that ordered the blood test (not HIV).

Enter the name of the healthcare provider or facility that ordered or scheduled the breathing test.

Enter the name of the healthcare provider or facility that ordered or scheduled the cardiac catheterization test.

Enter the reason why the participation in the support services plan or program was stopped.

Check this box if you are no longer participating in the plan or program and need to provide the date your participation began.

Enter the four-digit year when your participation in the support services plan or program began, if you are no longer participating.

Enter the two-digit month when your participation in the support services plan or program began, if you are no longer participating.

Enter the four-digit year when your participation in the support services plan or program stopped.

Enter the two-digit month when your participation in the support services plan or program stopped.

Check this box if you are still participating in the plan or program.

Enter the four-digit year when your participation in the plan or program began.

Enter the two-digit month when your participation in the plan or program began.

Enter the four-digit year for the expected completion date of your participation in the plan or program.

Enter the two-digit month for the expected completion date of your participation in the plan or program.

Check this box if you are currently working.

Check this box if you are not currently working.

Check this box if you had self-employment as a type of work since your last medical disability decision.

Check this box if you received wages from an employer as a type of work since your last medical disability decision.

Enter the date the report was completed.

Please enter the daytime phone number for this person.

Check this box if the person receiving disability benefits IS under age 14.

Check this box if the person receiving disability benefits is NOT under age 14.

Check this box if the person receiving disability benefits is under 18 years old.

Check this box if the person receiving disability benefits is 18 years old or older.

Enter the name of the healthcare provider or facility that ordered or scheduled the EEG (brain wave test).

Check this box to indicate that Wheelchair is an assistive device used.

Check this box if the eighth assistive device, a wheelchair, is always used.

Check this box if the eighth assistive device, a wheelchair, is sometimes used.

Enter the name of the health care provider who prescribed the eighth assistive device, a wheelchair, if known.

Enter the name of the healthcare provider or facility that ordered the EKG (heart test).

Provide a detailed explanation of any difficulties you experience with the tasks you marked.

Check this box to indicate that a hearing aid is the fifth assistive device used.

Check this box if the fifth assistive device, a hearing aid, is always used.

Check this box if the fifth assistive device, a hearing aid, is sometimes used.

Enter the name of the healthcare provider who prescribed this fifth assistive device (hearing aid), if known.

Enter the year of the last date you saw the fifth healthcare provider.

Enter the month of the last date you saw the fifth healthcare provider.

Enter the name of the fifth healthcare facility or office.

Enter the name of the fifth healthcare provider that treated you.

Enter the phone number of the fifth healthcare provider.

Describe the medical conditions that were treated or evaluated by the fifth healthcare provider.

Enter the street address of the fifth healthcare provider.

Enter the city of the fifth healthcare provider.

Enter the state or province of the fifth healthcare provider.

Enter the ZIP or postal code of the fifth healthcare provider.

Enter the country of the fifth healthcare provider, if not USA.

If the fifth medicine was prescribed, enter the name of the prescribing doctor, if known.

Enter the reason for taking the fifth medicine, if known.

Enter the name of the fifth medicine taken or currently being taken.

Check this box to indicate that Braces are your first assistive device.

Check this box if you always use your first assistive device, Braces.

Check this box if you sometimes use your first assistive device, Braces.

Provide the name of the health care provider who prescribed the first assistive device (Braces), if known.

Enter the year (YYYY) when you last saw the first healthcare provider, if known.

Enter the month (MM) when you last saw the first healthcare provider, if known.

Enter the name of the facility or office for the first healthcare provider.

Enter the name of the healthcare provider that treated you.

Enter the phone number for the first healthcare provider.

List the medical conditions that were treated or evaluated by this healthcare provider.

Enter the street address for the first healthcare provider.

Enter the city for the first healthcare provider.

Enter the state or province for the first healthcare provider.

Enter the ZIP or postal code for the first healthcare provider.

Enter the country for the first healthcare provider, if not USA.

If the first medicine was prescribed, enter the name of the doctor who prescribed it.

Enter the reason for taking the first medicine.

Check this box if eyeglasses are your fourth assistive device.

Check this box if you always use eyeglasses as your fourth assistive device.

Check this box if you sometimes use eyeglasses as your fourth assistive device.

Enter the name of the health care provider who prescribed the eyeglasses, if known.

Enter the year (YYYY) of the last date you were seen by the fourth health care provider.

Enter the month (MM) of the last date you were seen by the fourth health care provider.

Provide the name of the facility or office for the fourth health care provider.

Provide the name of the health care provider that treated you for the fourth health care provider.

Provide the phone number of the fourth health care provider.

Describe the medical conditions that were treated or evaluated by the fourth health care provider.

Provide the street address of the fourth health care provider.

Provide the city of the fourth health care provider.

Provide the state or province of the fourth health care provider.

Provide the ZIP or postal code of the fourth health care provider.

Provide the country of the fourth health care provider, if not USA.

Enter the name of the doctor who prescribed the fourth medicine, if known.

Enter the reason for taking the fourth medicine, if known.

Enter the name of the fourth medicine.

Enter the date of your last medical disability decision.

Provide the first, middle, last name, and suffix of the person receiving disability benefits.

Enter the Social Security Number of the person receiving disability benefits.

Provide the street address or PO Box for the mailing address, including apartment number if applicable.

Enter the city for your mailing address.

Enter the state or province for your mailing address.

Enter the ZIP or postal code for your mailing address.

Enter the country for your mailing address if it is not the USA.

Provide the street address for your residence, including apartment number if applicable, if it is different from your mailing address.

Enter the city for your resident address.

Enter the state or province for your resident address.

Enter the ZIP or postal code for your resident address.

Enter the country for your resident address if it is not the USA.

Provide your primary daytime phone number, including the area code, or IDD and country code if outside the USA or Canada.

Check this box if you can speak and understand English.

Check this box if you cannot speak and understand English.

If you cannot speak and understand English, specify the language you prefer.

Check this box if you can read and understand English.

Check this box if you cannot read and understand English.

Check this box if you can write more than your name in English.

Check this box if you cannot write more than your name in English.

Provide the first, middle, last name, and suffix of the person we can contact.

State the relationship of the contact person to the individual named in 1.A.

Check this box if you have not used any other names on your medical or educational records in the last 12 months.

Check this box if you have used any other names on your medical or educational records in the last 12 months.

Check this box if your residence address is not the same as your mailing address.

Check this box if your residence address is the same as your mailing address.

Provide your secondary daytime phone number, if available, including the area code, or IDD and country code if outside the USA or Canada.

Enter your email address.

List any other names used in the last 12 months on medical or educational records, such as maiden names, other married names, or nicknames.

Check this box if you have not received any education since your last disability decision; you may then proceed to section 7.B.

Check this box if you have received education since your last disability decision; you must then complete the section below regarding your education.

Enter the name of the school attended.

Enter the city of the school's mailing address.

Enter the state or province of the school's mailing address.

Enter the ZIP or postal code of the school's mailing address.

Enter the country of the school's mailing address, if not USA.

Enter the ending year of attendance at the school.

Enter the ending month of attendance at the school.

Enter the starting year of attendance at the school.

Enter the starting month of attendance at the school.

Enter the type of program or degree pursued at the school.

Enter the year when the program or degree was completed or is scheduled to be completed.

Enter the month when the program or degree was completed or is scheduled to be completed.

Check this box if you have not received any training (specialized job, trade, or vocational training) since your last disability decision; you may then proceed to section 7.C.

Check this box if you have received training (specialized job, trade, or vocational training) since your last disability decision; you must then complete the section below regarding your training.

Enter the name of the training facility.

Enter the phone number of the training facility.

Enter the mailing address of the training facility.

Enter the city of the training facility's mailing address.

Enter the state or province of the training facility's mailing address.

Enter the ZIP or postal code of the training facility's mailing address.

Enter the country of the training facility's mailing address, if not USA.

Enter the mailing address of the school.

Enter the type of program provided by the training facility.

Enter the year when the training program was completed or is scheduled to be completed.

Enter the month when the training program was completed or is scheduled to be completed.

Enter the date of next contact, if applicable.

Enter the date of last contact in the last 12 months, if known.

Enter the reason(s) for the contacts.

Enter the name of the organization.

Enter the phone number of the organization.

Enter the mailing address of the organization.

Enter the city of the organization's mailing address.

Enter the state or province of the organization's mailing address.

Enter the ZIP or postal code of the organization's mailing address.

Enter the country of the organization's mailing address, if not USA.

Enter the claim number, if applicable.

Enter the name of the contact person for the organization.

Enter any additional information not provided elsewhere that helps explain your disability and how it affects you, noting the section and question number if referring to specific items.

Provide details of the first physical and/or mental health condition that limits ability to work, or for a child under 18, limits their ability to do things like other children their age. Fill only if 'Age' is under 18

Provide details of the second physical and/or mental health condition that limits ability to work, or for a child under 18, limits their ability to do things like other children their age. Fill only if 'Age' is under 18

Provide details of the third physical and/or mental health condition that limits ability to work, or for a child under 18, limits their ability to do things like other children their age. Fill only if 'Age' is under 18

Provide details of the fourth physical and/or mental health condition that limits ability to work, or for a child under 18, limits their ability to do things like other children their age. Fill only if 'Age' is under 18

Provide details of the fifth physical and/or mental health condition that limits ability to work, or for a child under 18, limits their ability to do things like other children their age. Fill only if 'Age' is under 18

Provide the name of the healthcare provider or facility that ordered or scheduled the hearing test.

Enter the height measurement in feet.

Enter the height measurement in inches.

Enter the height measurement in centimeters.

Provide the name of the healthcare provider or facility that ordered or performed the HIV test.

Check this box if the person can speak and understand English.

Check this box if the person cannot speak and understand English.

Enter the preferred language if the person cannot speak and understand English.

Enter the street address or PO Box for the mailing address, including any apartment number if applicable.

Provide the city for the mailing address.

Enter the state or province for the mailing address.

Provide the ZIP code or postal code for the mailing address.

Enter the country for the mailing address, if it is not the USA.

Check this box if your medical conditions do not cause you to have difficulties doing everyday tasks.

Check this box if your medical conditions cause you to have difficulties doing everyday tasks, even if you receive help from others or use assistive devices.

Check this box if no providers listed in 3.D. ordered any medical tests for you within the last 12 months.

Check this box if any providers listed in 3.D. ordered medical tests for you within the last 12 months.

Enter the body part that was scanned during the MRI or CT scan.

Enter the name of the healthcare provider or facility that ordered or performed the MRI or CT scan.

Check this box if the person uses an assistive device not listed in the provided options and you will specify it as 'Other'.

Please specify the name of the ninth assistive device not listed in the standard options.

Check this box if the person always uses the 'Other' assistive device.

Check this box if the person sometimes uses the 'Other' assistive device.

Please provide the name of the healthcare provider who prescribed the ninth assistive device specified as 'Other', if known.

Specify the type or name of the 'Other' medical test performed.

Provide the name of the healthcare provider or facility that ordered or performed the specified 'Other' medical test.

Check this box if you have participated in or are currently participating in any support services to help you return to work since the date of your last medical disability decision.

Check this box if you have not participated in and are not currently participating in any support services to help you return to work since the date of your last medical disability decision.

Check this box if you have not taken any prescription or non-prescription medicines in the last 12 months.

Check this box if you have taken any prescription or non-prescription medicines in the last 12 months.

Enter the name of the healthcare provider or facility that ordered or performed the psychological/IQ test.

Check this box if you can read a simple message in the language identified in 7.C., such as a shopping list or short simple notes.

Check this box if you cannot read a simple message in the language identified in 7.C., such as a shopping list or short simple notes.

Check this box if the person has NOT seen or received treatment from a health care provider within the last 12 months.

Check this box if the person HAS seen or received treatment from a health care provider within the last 12 months.

Provide the daytime phone number where the report completer can be reached or left a message, including the area code, IDD, and country codes if residing outside the USA or Canada.

Enter the street address or PO Box of the report completer, including an apartment number if applicable.

Enter the city for the report completer's mailing address.

Enter the state or province for the report completer's mailing address.

Enter the ZIP or postal code for the report completer's mailing address.

Enter the country for the report completer's mailing address if it is not the USA.

Enter the full name (first, middle initial, last) of the person completing this report.

Enter the relationship of the person completing this report to the person listed in 1.A.

Check this box if canes are used as your second assistive device.

Check this box if you always use canes as your second assistive device, or if you always use them when outside your home, even if not always at home.

Check this box if you sometimes use canes as your second assistive device.

Provide the name of the health care provider who prescribed the canes, if known.

Enter the year you last saw the second health care provider.

Enter the month you last saw the second health care provider.

Enter the name of the second health care facility or office.

Enter the name of the second health care provider that treated you.

Enter the phone number of the second health care provider or facility.

Describe the medical conditions that were treated or evaluated by the second health care provider.

Enter the street address of the second health care provider or facility.

Enter the city of the second health care provider or facility.

Enter the state or province of the second health care provider or facility.

Enter the ZIP or postal code of the second health care provider or facility.

Enter the country of the second health care provider or facility, if not USA.

Please provide the name of the doctor who prescribed the second medicine, if known.

Please provide the reason for taking the second medicine, if known.

Please provide the name of the second medicine you are taking or have taken.

Check this box if a walker is an assistive device used.

Check this box if the walker is always used (or always used outside the home).

Check this box if the walker is sometimes used.

Enter the name of the health care provider who prescribed the seventh assistive device (Walker), if known.

Check this box if you use a screen reader as an assistive device.

Check this box if you always use the screen reader assistive device, even if you do not always use it at home but always use it when outside your home.

Check this box if you sometimes use the screen reader assistive device.

Provide the name of the health care provider who prescribed the sixth assistive device, a screen reader, if known.

Enter the name of the healthcare provider or facility that ordered or performed the speech/language test.

Enter the name of the facility or organization providing support services.

Enter the phone number for the support service facility or organization.

Enter the name of your counselor, instructor, or job coach.

Enter the city of the support service facility or organization's mailing address.

Enter the state or province of the support service facility or organization's mailing address.

Enter the ZIP or postal code of the support service facility or organization's mailing address.

Enter the country of the support service facility or organization's mailing address if it is not the USA.

Enter the street address or PO Box for the support service facility or organization, including suite or building number if applicable.

Check this box if you need help with or have difficulty dressing due to your medical conditions.

Check this box if you need help with or have difficulty bathing due to your medical conditions.

Check this box if you need help with or have difficulty caring for your hair due to your medical conditions.

Check this box if you need help with or have difficulty walking due to your medical conditions.

Check this box if you need help with or have difficulty standing due to your medical conditions.

Check this box if you need help with or have difficulty sitting due to your medical conditions.

Check this box if you need help with or have difficulty concentrating due to your medical conditions.

Check this box if you need help with or have difficulty taking medicine due to your medical conditions.

Check this box if you need help with or have difficulty preparing meals due to your medical conditions.

Check this box if you need help with or have difficulty feeding yourself due to your medical conditions.

Check this box if you need help with or have difficulty shopping due to your medical conditions.

Check this box if you need help with or have difficulty lifting objects due to your medical conditions.

Check this box if you need help with or have difficulty using your arms due to your medical conditions.

Check this box if you need help with or have difficulty remembering due to your medical conditions.

Check this box if you need help with or have difficulty doing chores (inside/outside of house) due to your medical conditions.

Check this box if you need help with or have difficulty driving or using public transportation due to your medical conditions.

Check this box if you need help with or have difficulty understanding or following directions due to your medical conditions.

Check this box if you need help with or have difficulty managing money due to your medical conditions.

Check this box if you need help with or have difficulty getting along with people due to your medical conditions.

Check this box if you need help with or have difficulty using your hands or fingers due to your medical conditions.

Check this box if you need help with or have difficulty seeing, hearing, or speaking due to your medical conditions.

Check this box if crutches are the third assistive device you use.

Check this box if you always use crutches as your third assistive device.

Check this box if you sometimes use crutches as your third assistive device.

Provide the name of the health care provider who prescribed the crutches, if known.

Please provide the four-digit year for the last date you were seen by the third health care provider.

Please provide the two-digit month (MM) for the last date you were seen by the third health care provider.

Please provide the name of the third facility or office that provided healthcare.

Please provide the name of the third health care provider that treated you.

Please provide the phone number for the third health care provider.

Please describe the medical conditions that were treated or evaluated by the third health care provider.

Please provide the street address for the third health care provider.

Please provide the city for the third health care provider's address.

Please provide the state or province for the third health care provider's address.

Please provide the ZIP or postal code for the third health care provider's address.

Please provide the country for the third health care provider's address, if not USA.

Enter the name of the doctor who prescribed the third medicine, if known.

Enter the reason for taking the third medicine, if known.

Enter the name of the third medicine.

Enter the name of the healthcare provider or facility that ordered or scheduled the treadmill (exercise) test.

Check this box if a vision test was among the services, tests, or evaluations provided.

Check this box if a psychological or IQ test was among the services, tests, or evaluations provided.

Check this box if work classes were among the services, tests, or evaluations provided.

Check this box if a hearing test was among the services, tests, or evaluations provided.

Check this box if a work evaluation was among the services, tests, or evaluations provided.

Provide a detailed explanation of any other types of services, tests, or evaluation received that were not listed in the checkboxes above.

Check this box if other types of services, tests, or evaluations not listed were provided, and provide an explanation.

Provide the name of the healthcare provider or facility that ordered the vision test.

Enter the individual's weight in pounds.

Enter the individual's weight in kilograms.

Check this box if someone other than the persons listed in 1.A. or 2.A. is completing this report, then complete the section below.

Check this box if the person listed in section 1.A. is completing this report.

Check this box if the person listed in section 2.A. is completing this report.

Check this box if you have worked since the date of your last medical disability decision.

Check this box if you have not worked since the date of your last medical disability decision.

Check this box if you can write a simple message, such as a shopping list or short simple notes, in the language identified in 7.C.

Check this box if you cannot write a simple message, such as a shopping list or short simple notes, in the language identified in 7.C.

Enter the written language you use every day in most situations.

Please list the body part, if known, where the X-ray was performed.

Please provide the name of the healthcare provider or facility associated with the X-ray.