Form Pain Questionnaire Pain Questionnaire Pain Questionnaire

Cardiac Questionnaire Doctor-Adult
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Patient Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
CARDIAC QUESTIONNAIRE

1. Diagnosis: ________________________

Date of diagnosis: ____________________

2. Date and findings of most recent exam: __________________________________________
___________________________________________________________________________
3. Would undergoing exercise testing pose significant risk for your patient?

Yes

No

4. If the patient has chest pain, is it related to a cardiac condition?
Yes
No If no, what
non-cardiac condition is causing chest pain? _______________________________________
5. Has the patient experienced cyanosis at rest?

Yes

No On exertion?

Yes

No

6. Describe the patient’s cardiac signs and symptoms (for example, dyspnea, fatigue,
palpitations, chest discomfort, edema, varicosities, stasis dermatitis, ulcerations,
claudication). _______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. Describe the location, duration, and frequency of the patient’s symptoms. _______________
___________________________________________________________________________
8. Describe any precipitating factors (for example, physical activity, eating, cold air). ________
___________________________________________________________________________
9. What relieves the patient’s symptoms (for example, rest, position, medication)? __________
___________________________________________________________________________
10. Are the symptoms acute or chronic? _____________________________________________
11. Current New York Heart Association class rating: _________
Based on this rating
describe the patient’s physical limitations (for example, difficulty with household tasks,
walking, stairs, lifting). _______________________________________________________
___________________________________________________________________________

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12. Describe any evidence of neurological complications (for example, ataxia, paralysis,
aphasia). ___________________________________________________________________
___________________________________________________________________________
13. Is there evidence of end-organ damage as a result of hypertension (for example, kidney
failure, retinopathy)?
Yes
No If yes, describe. ______________________________
___________________________________________________________________________
14. Treatment:
MEDICATION

DOSAGE AND FREQUENCY

PAST TREATMENT OR
RECOMMENDATION(S) (for example,
angioplasty, CABG, pacemaker)

DATE PERFORMED OR SCHEDULED

15. Have the symptoms persisted despite treatment? ___________________________________
___________________________________________________________________________
16. Describe any restrictions to work-related activities, if not previously provided (for example,
walking, lifting, carrying).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

NOTE: Please submit copies of tracings, testing, and laboratory results, if you have not provided
them previously.
___________________________
Physician’s Signature

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

Paperwork Reduction Act Statement – 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 provide this information unless we display a

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valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Cardiac Questionnaire Clmt-Adult
[Standard Header]
Claimant Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
CARDIAC QUESTIONNAIRE
If you need more space, please attach additional page(s).
1. Do you have any chest discomfort?

Yes

No

a. How often does it occur? ________________________________________________
_____________________________________________________________________
b. What brings on your chest discomfort? _____________________________________
_____________________________________________________________________
c. What does it feel like? __________________________________________________
_____________________________________________________________________
d. How long do episodes last? ______________________________________________
e. What relieves it? ______________________________________________________
_____________________________________________________________________
f. Does it radiate? If so, where? _____________________________________________
g. Does it occur at rest? ___________________________________________________
h. Does it awaken you from sleep? __________________________________________
2. Do you have shortness of breath?

Yes

No

a. When does it occur? ____________________________________________________
b. What brings it on? _____________________________________________________
c. What relieves it? ______________________________________________________
d. How far can you walk without stopping to rest? ______________________________
e. How many flights of stairs can you climb without stopping to rest? _______________

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3. Do you have additional symptoms (for example, fatigue, weakness, lightheadedness).
Yes
No If yes, describe.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4. List current cardiac medication(s).
MEDICATION

DATE
STARTED

IF PRESCRIBED,
NAME OF
DOCTOR

DOSAGE
AND
FREQUENCY

SIDE
EFFECT(S)

5. Describe any activities you have stopped due to shortness of breath or chest discomfort.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. If you have seen any medical professionals for your cardiac condition since you filed your
claim, complete the chart below.
NAME

ADDRESS AND PHONE
NUMBER

_________________________________________
Name of person completing this form (Please print)

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DATE OF
LAST VISIT

DATE OF
NEXT VISIT

____________ ___________________
Date
Phone

_________________________________________
Address

____________
City

________
State

________
ZIP

Paperwork Reduction Act Statement – 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 provide this information unless we display a
valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Cardiac Questionnaire Doctor-Child
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Child Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
CHILD CARDIAC QUESTIONNAIRE
1. Diagnosis: ________________________

Date of diagnosis: ____________________

2. Date and findings of most recent exam: __________________________________________
___________________________________________________________________________
3. Current height and percentile: __________
4. For children under two:

Current weight and percentile: __________

Birth Length: _____________ Birth Weight: ________________

5. Has the child had involuntary weight loss or failure to gain weight that has persisted for two
months or longer?
Yes
No
If yes, provide copies of records to include
longitudinal history of height, weight, and growth percentiles. ________________________
___________________________________________________________________________
___________________________________________________________________________
6. For children age six or older, would undergoing exercise testing pose significant risk for the
child?
Yes
No
7. If the child has chest pain, is it related to a cardiac condition?
Yes
No
If no, what
non-cardiac condition is causing chest pain? _______________________________________
8. Describe the child’s cardiac signs and symptoms (for example, syncope, cyanosis, edema,
dyspnea, weakness, palpitations, weight loss or gain). _______________________________
___________________________________________________________________________
___________________________________________________________________________
9. Describe the location, duration, and frequency of the child’s symptoms. _________________
___________________________________________________________________________
10. Describe any precipitating factors (for example, physical activity, eating, cold air). ________
___________________________________________________________________________
11. What relieves the child’s symptoms (for example, rest, position, medication)? ____________
___________________________________________________________________________

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12. Are the symptoms acute or chronic? _____________________________________________
13. Describe any evidence of neurological complications (for example, weakness, spasticity,
incoordination, ataxia, tremor) resulting from the child’s cardiac condition(s).
___________________________________________________________________________
___________________________________________________________________________
14. Is there evidence of end-organ damage as a result of hypertension (for example, kidney
failure, retinopathy)?
Yes
No If yes, describe.______________________________
___________________________________________________________________________
15. Describe any cognitive deficits resulting from the child’s cardiovascular disease or
treatments for the cardiac condition(s). _____________________________________
___________________________________________________________________________
___________________________________________________________________________
16. Treatment:
MEDICATION

DOSAGE AND FREQUENCY

PAST TREATMENT OR
RECOMMENDATION(S) (for example,
pacemaker, defibrillator, corrective surgery)

DATE PERFORMED OR SCHEDULED

17. Have the symptoms persisted despite treatment? ___________________________________
___________________________________________________________________________
18. Describe any restrictions to age appropriate activities, if not previously provided (for
example, acquiring and using information, attending and completing tasks, interacting and
relating with others, moving about and manipulating objects, self-care).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

NOTE: Please submit copies of tracings, testing, and laboratory results, if you have not provided
them previously.
.

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___________________________
Physician’s Signature

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

Paperwork Reduction Act Statement – 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 provide this information unless we display a
valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Epilepsy Questionnaire Doctor-Adult
[Standard Header]
Patient Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
EPILEPSY QUESTIONNAIRE
1. Date of most recent examination: _______________________________________________
2. Diagnoses: _________________________________________________________________
3. Indicate the type of seizures:

Convulsive
Non-Convulsive

4. Dates of last two seizures: ____________________

________________________

5. Describe typical seizures (include all associated phenomena, such as aura, loss of
consciousness, tonic or clonic movement, incontinence, alteration of awareness,
unconventional behavior, duration, etc.). __________________________________________
___________________________________________________________________________
___________________________________________________________________________
6. Describe postictal manifestations and duration. ____________________________________
___________________________________________________________________________
___________________________________________________________________________
7. If convulsive, when do episodes occur?
Day (with loss of consciousness and convulsive seizures)
Night
8. Seizures witnessed by physician or staff member?
Yes
No If yes, describe.
___________________________________________________________________________
___________________________________________________________________________
9. Treatment:
MEDICATION

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DOSAGE AND
FREQUENCY

SIDE EFFECT(S)

Other treatment: _____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
10. Are seizures controlled with medication?
Yes
No If no, explain. ______________
___________________________________________________________________________
___________________________________________________________________________
11. Frequency of seizures after prescribed treatment: ___________________________________
___________________________________________________________________________
___________________________________________________________________________
12. Serum levels:
DRUG

DATE

RESULT

13. If serum drug levels are therapeutically inadequate, explain further. ____________________
___________________________________________________________________________
___________________________________________________________________________
14. Describe any functional limitations resulting from the patient’s condition (for example,
driving, physical activity, hazardous conditions). ___________________________________
___________________________________________________________________________
___________________________________________________________________________
15. Describe any restrictions to work-related activities, if not previously provided (for example,
walking, lifting, carrying).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

NOTE: Please submit copies of any testing and laboratory results, if you have not provided them
previously.
___________________________
Physician’s Signature

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

[Standard footer]

Paperwork Reduction Act Statement – 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 provide this information unless we display a
valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Seizure Questionnaire Clmt-Adult
[Standard Header]
Claimant Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
SEIZURE QUESTIONNAIRE
If you need more space, please attach additional page(s).
1. Do you have seizures?

Yes

No

a. When was your first seizure? _____________________________________________
b. When did you have your last seizure? ______________________________________
c. Do your seizures usually occur during the day, during the night, or both? Please
explain. ______________________________________________________________
_____________________________________________________________________
d. How long do the seizure(s) last? __________________________________________
e. How often do seizures occur? ____________________________________________
f. List the approximate date(s) of seizure(s) in the last 12 months. _________________
_____________________________________________________________________
_____________________________________________________________________
g. Describe what happens before, during, and after you have a seizure and how long
until you can resume normal activity. ______________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. Describe any event(s) that cause your seizure(s). ___________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
3. List current seizure medication(s).
MEDICATION

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DATE
STARTED

IF PRESCRIBED,
NAME OF

DOSAGE
AND

SIDE
EFFECT(S)

DOCTOR

FREQUENCY

4. Have you visited an emergency room for seizures? If so, when and where? ______________
___________________________________________________________________________
5. If you have seen any medical professionals for your seizures since you filed your claim,
complete the chart below.
NAME

ADDRESS AND PHONE
NUMBER

DATE OF
LAST VISIT

DATE OF
NEXT VISIT

6. Provide the name, address, and phone number of any medical professionals and other
individuals (including a non-family member) who have witnessed your seizure(s).
NAME

ADDRESS

PHONE NUMBER

_________________________________________
Name of person completing this form (Please print)

____________ ___________________
Date
Phone

_________________________________________
Address

____________
City

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________
State

________
ZIP

Paperwork Reduction Act Statement – 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 provide this information unless we display a
valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Seizure Questionnaire Witness
[Standard Header]
Individual’s Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
SEIZURE WITNESS QUESTIONNAIRE
If you need more space, please attach additional page(s).
1. What is your relationship to this individual? _______________________________________
2. How long have you known this individual? _______________________________________
3. How often do you see this individual? ____________________________________________
4. How many times have you seen this individual have a seizure? ________________________
5. What is the approximate date of the last seizure you saw? ____________________________
6. Were there any changes in the individual’s behavior just before a seizure?
Yes
No
If yes, explain. ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7. Describe what happened to the individual during a seizure (for example, did the individual
lose consciousness, fall down, stare into space, lose bowel or bladder control, bite tongue,
have repeated body movements, suffer an injury)? __________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8. Describe any problems the individual had after a seizure (for example, confusion, tiredness,
difficulty talking or walking) and how long the problems lasted. _______________________
___________________________________________________________________________
___________________________________________________________________________
9. Did the individual remember having a seizure?

Yes

No

10. How long does a seizure typically last? ___________________________________________
11. In addition to seizures you have witnessed, do you know about any other seizures?
Yes
No If yes, explain. _______________________________________________

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___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_________________________________________
Name of person completing this form (Please print)

____________ ___________________
Date
Phone

_________________________________________
Address

____________
City

________
State

________
ZIP

Paperwork Reduction Act Statement – 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 provide this information unless we display a
valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 0960-0555. We
estimate that it will take between 5-30 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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See Revised Privacy Act and
PRA Statements attached

PRIVACY ACT STATEMENT
Collection and Use of Information by the Social Security Administration

The Privacy Act of 1974 (5 U.S.C. § 552a) requires us to provide certain facts to each person from whom we
request and collect information in order to administer our programs. These facts include:
• the statutory authority for the request;
• why we need the information;
• whether it is voluntary or mandatory for you to give us the information and the effects, if any, of not
giving us the information; and
• the uses we may make of the information you give us.
The following sections explain our collection, use, and disclosure of the information you give us. If you have
any questions about your rights and responsibilities under the Privacy Act, you may contact any local Social
Security office.
Our authority to collect information
Our specific authority to collect information is found
in sections 205(a), 702, 1631(e)(1)(A) and (B),
1631(f), 1872, and 1875 of the Social Security Act
(the Act), as amended. Additional authority is in
part B of the Federal Coal Mine Health and Safety
Act of 1969.

information to another agency or person without
your written consent. We make these disclosures
for the following reasons:
•
•
•

Why we need the information
We collect information from you in order to
administer our programs. Specifically, the
information we request enables us to:
•
•
•
•
•

assign Social Security numbers;
establish and maintain earnings records;
determine entitlement of applicants and
their families to insurance coverage and or
benefit payments;
issue payments in the right amount for the
right months to people entitled to them; and
conduct program-oriented research in areas
of income distribution and maintenance.

Is providing information voluntary or
mandatory?
It is not mandatory for you to give us the
information we request except in certain instances
explained below. It is usually to your advantage to
comply with our request for information. Failure to
do so, however, could prevent an accurate and
timely decision on a claim you file or result in the
loss of some benefit or service.
Our use(s) of the information you give us
We use the information you give us to administer
our programs. Sometimes we must disclose the

•

to enable a third party or agency to assist us
in establishing your right to benefits or
coverage;
to comply with Federal laws;
to make eligibility determinations in similar
Federal, State, and local health and income
maintenance programs;
to facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of our programs.

We may also use the information you give us when
we match records by computer. Computer
matching programs compare our records with those
of other Federal, State, or local government
agencies. We use the information from these
matching programs to establish or verify a person’s
eligibility for Federally-funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of the information
you give us is available in our Privacy Act Systems
of Records Notices. For example, the application
for benefits and supporting documentation of the
factors of entitlement and continuing eligibility is
contained in our Claims Folder System (60-0089);
medical information, doctors’ reports, and State
disability determinations related to a disability claim
is contained in our National Disability Determination
Services File System (60-0044). Additional
information regarding this form, routine uses of
information, and other Social Security programs is
available from our Internet website at
www.socialsecurity.gov or at your local Social
Security office.
Form SSA-5000 (05-2011)

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d) and 1631(d) and (e) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on any claim filed.
We will use the information to make a determination regarding your ability to perform workrelated activities. We may also share your information for the following purposes, called routine
uses:
1. To private medical and vocational consultants for use in making preparation for, or
evaluating the results of, consultative medical examination or vocational assessments
which they were engaged to perform by SSA or a State agency acting in accord with
sections 221 or 1633 of the Act; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under this routine use only in situations in which SSA may
enter into a contractual or similar agreement with a third party to assist in accomplishing
an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0044, entitled National Disability Determination Services File System and 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement - 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
(OMB) control number. We estimate that it will take about 20 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.