​​​Social Security Disability and Veterans Compensation Attorneys

SSA Lawyers P.A.

 
If you need more space, please attach additional page(s).

 

1) Describe where the pain is located. Does it stay in one location or move to other areas of your

body? ______________________________________ __________________________________

 ______________________________________________________________________________ 

 

2) Describe the pain (for example, burning, dull, sharp, aching) and severity (for example, mild, moderate, severe).
 
_____________________________________________________________________________________

 

3) How often do you have pain? When does it occur? _________________________________________

 _____________________________________________________________________________________

 4) How long does it last?  -----------------------------------

 
5) What activities or circumstances cause or increase the pain?

 _____________________________________________________________________________________

 
6) Has the pain limited or restricted your activities? __ Yes __ No

If yes, explain and provide examples. _____________________________________________________________________________________

 _____________________________________________________________________________________

 
7) Does pain affect your ability to think and concentrate? __ Yes __No

 If yes, explain and provide examples. _______________________________________________________

 _____________________________________________________________________________________

 ______________________________________________________________________________________
 

List current pain rnedication (s).

 

MEDICATION NAME, DOSAGE, AND FREQUENCY      DATE STARTED     IF PRESCRIBED, NAME OF DOCTOR     SIDE EFFECT(S)

 _____________________________________________       _______________    __________________________________    _______________

 _____________________________________________       _______________    __________________________________    _______________

  _____________________________________________       _______________    __________________________________    _______________

  _____________________________________________       _______________    __________________________________    _______________

  _____________________________________________       _______________    __________________________________    _______________

  _____________________________________________       _______________    __________________________________    _______________

 
8)            Do your medication(s) relieve the pain? __ Yes __No


9)            Describe any other treatments you use to relieve your pain (for example, hot baths, therapy, exercise. How well do they work? How often do you use them?

 _____________________________________________________________________________________________________________________________

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