Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
This appendix contains two draft forms, one for children and one for adults, that could serve as templates to facilitate the collection of comprehensive information about the health conditions and symptoms related to sickle cell disease (SCD) that are experienced by an individual applying for disability benefits through the Social Security Administration (SSA).1 The forms presented here are adapted versions of draft forms submitted to the committee by Community Legal Services, Inc., Philadelphia.2 They are designed to be completed by the health care providers treating an applicant with SCD and returned to SSA along with the relevant medical records. The information collected on the cumulative burden of SCD could help inform the consideration of combinations of vaso-occlusive pain crises, hospitalizations, chronic pain, severe fatigue, and SCD-related health conditions across different body systems, including depression, anxiety, or trauma, that are experienced by the individual as well as the effects of these issues on the person’s functioning. The forms can be modified to specify the information that SSA would find most helpful for determining whether the individual’s impairments meet or medically equal listing criteria as well as other information of use to SSA in making disability determinations.
___________________
1These forms are for example purposes only; they are not official forms in use by SSA and should not be used in any official manner.
2Jonathan Stein. 2025. Memo to NASEM Sickle Cell Disease Disability Evaluation Committee Members. Community Legal Services, Inc., Philadelphia. Submitted to committee on February 25, 2025.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
Suggested Citation:
"Appendix B: Draft Medical Report Forms for Children and Adults with Sickle Cell Disease." National Academies of Sciences, Engineering, and Medicine. 2025. Sickle Cell Disease in Social Security Disability Evaluations. Washington, DC: The National Academies Press.
doi: 10.17226/29319.
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