Form SSA-3371-BK Pain Report-Child

Form SSA-3371-BK (09-2016) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 9
OMB No. 0960-0540

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 (09-2016) UF

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PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 1614(a)(3)(H)(i), 1631(d)(1), and 1631(e)(1) of the Social Security Act, as amended, allow us to
collect this information. We will use the information you provide to make a decision on the named
individual's disability claim.
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 the named individual's claim.
We rarely use the information you supply for any purpose other than what we state above, however, we
may use the information for the administration of our programs, including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy
Act System of Records Notices, 60-0089, entitled Claims Folder System, and 60-0103, entitled
Supplemental Security Income and Special Veterans Benefits. Additional information about these and
other system of records notices and our programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility for
federally funded or administered benefit programs and for repayment of incorrect payments or
delinquent debts under these programs.

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 15 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.

Form SSA-3371-BK (09-2016) UF

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Pain Report - Child

SECTION 1 - IDENTIFYING INFORMATION
1A. 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):

City

State

ZIP Code

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.

SECTION 2 - FIRST PAIN
2A. 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.

Form SSA-3371-BK (09-2016) UF

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

Minute

Day

Month

Hour

Week

Year

or

Continuously

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
the pain
appears
stop place
the child
Removeways
thethat
comma
after
the Etoand
a from doing things other children his or her age can do. If the child has not
period, always
"E." 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?

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

Form SSA-3371-BK (09-2016) UF

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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
(for example,
1-2 pills)

How Often Taken?
(for example,
every 4 hours)

Relieves
the pain?

Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never

I. Does the medication cause any side effects?

Yes

If "yes," please explain:

SECTION 3 -SECOND PAIN
3A. 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.

No

Form SSA-3371-BK (09-2016) UF

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

Minute

Day

Month

Hour

Week

Year

or

Continuously

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

Remove
thethat
comma
after
the "E"
andthe child from doing things other children his or her age can do. If the child has not
ways
the pain
appears
to stop
had
pain, explain how the pain has changed the way(s) that he or she can do things.
place aalways
period,
"E."

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

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

Form SSA-3371-BK (09-2016) UF

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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
(for example,
1-2 pills)

How Often Taken?
(for example,
every 4 hours)

Relieves
the pain?

Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never

Yes

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

SECTION 4 -THIRD PAIN
4A. 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.

No

Form SSA-3371-BK (09-2016) UF

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

Minute

Day

Month

Hour

Week

Year

or

Continuously

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
waysthe
thatcomma
the pain after
appears
child
Remove
thetoEstop
andtheadd
a 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.
period, "E."

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

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

Form SSA-3371-BK (09-2016) UF

Page 9 of 9

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
(for example,
1-2 pills)

How Often Taken?
(for example,
every 4 hours)

Relieves
the pain?

Always
Sometimes
Never
Always
Sometimes
Never
Always
Sometimes
Never

Yes

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

SECTION 5 - REMARKS

No