Application for SSDI Pain Questionnaire

SSDI Pain QuestionnaireIf you file for social security disability benefits and need to prove the extent of pain for your case, you may be asked to complete a SSDI Pain Questionnaire.  This might come with other forms for you to complete and can be a specific form from your state because it is not an official SSA form. If you didn’t receive the form but want to supplement your application by describing pain that you suffer, we have developed a generic SSDI Pain Questionnaire that you can complete and send as additional documentation to support your disability claim. It is important to understand that pain itself is not considered a disability, rather the symptom of some other condition.  Before completing the Pain Questionnaire we recommend that you read about how Pain is evaluated by the Social Security Administration. Evaluation of Symptoms, Including Pain in the Social Security Administration law manual can help understand the way pain relates to a disability in the eyes of the SSA.

Use our generic SSDI PAIN QUESTIONNAIRE form

SSDI Pain Questionnaire

PAIN QUESTIONNAIRE SINCE YOUR DISABILITY BEGAN

Please complete the following questions for your primary area or source of pain. If you have secondary or additional source of pain, please also complete the Supplemental Pain Questionnaire. Please explain your answers by giving us detailed examples. If you need more room, you may use more sheets of paper. Be sure to sign and date this form at the end in the space provided.

1. Please describe the pain that prevents you from carrying out your normal day. Be specific.

a. When did it begin?

b. Where is it currently located?

c. Has it changed in nature and/or location since it began? c Yes c No If YES, how has it changed?

d. Does it spread to other places? c Yes c No If YES, where?

e. Is the pain constant? c Yes c No If NO, how often does it occur?

What brings it on?

How long does it last?

2. Do you take pain medication(s) for your condition? c Yes c No If YES, please list the name of medication, amount currently taken, how often taken and how long used.

a. Does the medication relieve the pain? c Yes c No If YES, how soon? For how long?

b. Does the medication cause any side effects? c Yes c No If YES, please describe.

3. Please describe any devices worn or used to relieve the pain.

4. Please describe any other things done to relieve the plain.

5. When did the pain first begin to affect activities?

6. Please describe any change in activities since the pain began.

7. Please describe current daily activities. (Walking, shopping, household chores, driving, socializing, etc.)

8. Are there any other statements you wish to make about the pain?

9. Please list anyone, other than doctors (we may contact) who has knowledge about the effects of this pain:

SUPPLEMENTAL PAIN QUESTIONNAIRE

(For secondary or additional sources, or areas of pain)

1. Please describe the pain that prevents you from carrying out your normal day. Be specific.

a. When did it begin?

b. Where is it currently located?

c. Has it changed in nature and/or location since it began? c Yes c No If YES, how has it changed?

d. Does it spread to other places? c Yes c No If YES, where?

e. Is the pain constant? c Yes c No If NO, how often does it occur?

What brings it on?

How long does it last?

2. Do you take pain medication(s) for your condition? c Yes c No If YES, please list the name of medication, amount currently taken, how often taken and how long used.

c. Does the medication relieve the pain? c Yes c No If YES, how soon? For how long?

d. Does the medication cause any side effects? c Yes c No If YES, please describe.

3. Please describe any devices worn or used to relieve the pain.

4. Please describe any other things done to relieve the plain.

5. When did the pain first begin to affect activities?

6. Please describe any change in activities since the pain began.

7. Please describe current daily activities. (Walking, shopping, household chores, driving, socializing, etc.)

8. Are there any other statements you wish to make about the pain?

9. Please list anyone, other than doctors (we may contact) who has knowledge about the effects of this pain:

POST YOUR ACTUAL SOCIAL SECURITY DISABILITY APPLICATION EXPERIENCE HERE: This is a “user to user” site and the primary mode of support is peer-to-peer, meaning users helping other users. Admin and moderators are not always present or may not have answers to questions. Users becomes more informed when they are here often to read and comment. We call them Top Contributors. We are not a group of experts, merely individuals who have learned more than we ever wanted to know about the social security disability process.

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