Form SSA-3371-BK Pain Report-Child

Pain Report - Child
Filling Out The Pain Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR
SOCIAL SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the disability
decision on this disability claim. You can help them by completing as much of the form as you
can.
• Print or type.
• Do not ask a doctor or hospital to complete this form.
• Be sure to explain your answer if an explanation is requested or needed.
• If more space is needed to answer any of the questions, please use the

"REMARKS" section and show the number of the question being answered.
The information we ask for on this form tells us about any pain the child has. The information
includes where the pain is, how long the pain lasts, how often the pain occurs, how bad the pain
is, what causes the pain, what relieves the pain and what treatment or medication makes it better.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.

Form

SSA-3371-BK (4-2006) ef (04-2006)

Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy
And Paperwork
Reduction Acts

The Social Security Administration is authorized to collect the
information on this form under sections 205(a), 223(d) and 1631(e)
(1) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on the named
claimant's claim. While giving us the information on this form is
voluntary, failure to provide all or part of the requested information
could prevent an accurate or timely decision on the named claimant's
claim. Although the information you furnish is almost never used for
any purpose other than making a determination about the claimant's
disability, such information may be disclosed by the Social Security
Administration as follows: (1) to enable a third party or agency to
assist Social Security in establishing rights to Social Security
benefits and/or coverage; (2) to comply with Federal Laws requiring
the release of information from Social Security records (e.g., to the
Government Accountability Office and the Department of Veterans
Affairs); and (3) to facilitate statistical research and such activities
necessary to assure the integrity and improvement of the Social
Security programs (e.g., to the Bureau of the Census and private
concerns under contract to Social Security).
We may also use the information you give us when we match
records by computer. Matching programs compare our records with
those of other Federal, State, or local government agencies. Many
agencies may use matching programs to find or prove that a person
qualifies for benefits paid by the Federal government. The law
allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you
provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social
Security office.
PAPERWORK REDUCTION ACT: This information collection
meets the requirements of 44 U.S.C. § 3507, as amended by Section
2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will
take about 15 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at
1-800-772-1213. You may send comments on our time estimate
above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.

Form

SSA-3371-BK (4-2006) ef (04-2006)

Form Approved
OMB No. 0960-0540

SOCIAL SECURITY ADMINISTRATION

PAIN REPORT - CHILD

SECTION 1 - IDENTIFYING INFORMATION

1. A. Print NAME OF CHILD:
FIRST

MIDDLE

LAST

B. CHILD'S SOCIAL SECURITY NUMBER:

-

-

C. YOUR NAME (if you represent an agency, provide agency name):

DAYTIME TELEPHONE NUMBER (including Area Code):

(

)

-

MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route):

STATE

CITY

ZIP CODE

PAIN DESCRIPTION
Please answer the questions on the following pages concerning the pain related to the child's illnesses or
injuries. Answer the questions the best you can based on what the child has told you and what you have
observed. If he or she has pain in more than one part of his or her body (for example, chest pain and ear
pain), please describe each one separately. Use Section 2 for the first pain, Section 3 for the second pain,
and so on. If he or she has pain in more than three parts of the body, use Section 5, REMARKS, to
describe the other pains.
Form

SSA-3371-BK (4-2006) ef (04-2006)

Prior edition may be used until stock is exhausted

Page 1

SECTION 2 - FIRST PAIN

2. A. Where does the child have pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D.How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;
describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form

SSA-3371-BK (4-2006) ef (04-2006)

Page 2

2. G. What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
(for example,
Taken?
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never

Always

Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form

SSA-3371-BK (4-2006) ef (04-2006)

YES

NO

Page 3

SECTION 3 - SECOND PAIN

3. A. Where does the child have the pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D. How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;
describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form

SSA-3371-BK (4-2006) ef (04-2006)

Page 4

3. G. What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
(for example,
Taken?
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never
Always
Month/Day/Year

Sometimes
Never
Always
Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form

SSA-3371-BK (4-2006) ef (04-2006)

YES

NO

Page 5

SECTION 4 - THIRD PAIN

4. A. Where does the child have the pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D. How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;
describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form

SSA-3371-BK (4-2006) ef (04-2006)

Page 6

4. G. What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
(for example,
Taken?
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never
Always
Month/Day/Year

Sometimes
Never
Always
Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form

SSA-3371-BK (4-2006) ef (04-2006)

YES

NO

Page 7

SECTION 5 - REMARKS

Form

SSA-3371-BK (4-2006) ef (04-2006)

Page 8