For any performing any kind of job the first criteria that must be hundred percent perfect is fitness. No matter what the job, one would never be able to perform it properly while in pain. Whereas, temporary illness may be ignored, chronic pain can turn out to be headache for any employee. While the severe pain hinders performance, for most people the idea of rest may mean severe financial crises. Although, most employees are offered the option of seeking social security disability benefits, proving the intensity of one’s pain that is proving oneself to be eligible for such benefits can be challenging. Social security pain questionnaire serves this purpose by offering a healthy mode of examining whether one deserves to reap the benefits of such social security schemes.

Sample Social Security Pain Questionnaire

Please Provide Personal Details:

 Claimant’s Name: ___________________________

Age: _____________________________

Job position:

Social security no.:


  1. Where exactly does the claimant feel the pain?
  1. When did the claimant first report the pain?
  1. Since when and how did the pain begin hamper the claimant’s job activities?
  1. Is the claimant under medication for the pain? Mention details.
    • Name of the doctor consulted:
    • Date:
    • Name and address of the clinic:
    • Medications prescribed by the doctor:
  1. Medicine
  2. Purpose
  3. Dosage
  1. Did the claimant have any clinical evidence, that is, report of tests done to diagnose the pain? Mention details.
    • Tests done
    • Purpose
    • Inference
    • Name of the center
    • Medical facility used:
  1. Can the claimant provide a tentative duration for the prescribed medical treatment?