Category III - Pain, Other Symptoms, Impairment Information - Current

Form Approved
OMB No. 0960-0555

Cardiac Questionnaire Clmt-Adult

[Standard Header]
Claimant Name: [Clmt Full Name]
{barcode}

PLEASE COMPLETE AND RETURN BY {current + 14 days}
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? _______________
3) Do you have additional symptoms (for example, fatigue, weakness, lightheadedness)?
Yes
No If yes, describe.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4) List current cardiac medication(s).
MEDICATION,
DOSAGE, AND
FREQUENCY

DATE
STARTED

IF PRESCRIBED, NAME
OF HEALTH CARE
PROFESSIONAL

SIDE EFFECT(S)

5) Describe any activities you have stopped due to shortness of breath or chest discomfort.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6) If you have seen any health care professionals for your cardiac condition since you filed your
claim, complete the chart below.
NAME OF HEALTH CARE
PROFESSIONAL

ADDRESS AND PHONE NUMBER

DATE OF LAST
VISIT AND NEXT
SCHEDULED
APPOINTMENT (IF
ANY)

_________________________________________
Name of person completing this form (Please print)

____________ ___________________
Date
Phone

_________________________________________
Address

____________ ________
City
State

________
ZIP

Form Approved
OMB No. 0960-0555

Seizure Questionnaire Clmt-Adult

[Standard Header]
Claimant Name: {clmt_full_name}
{barcode}

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

Yes

No

If yes:
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 event(s) that cause your seizure(s).

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3) List current seizure medication(s).
MEDICATION, DOSAGE,
AND FREQUENCY

DATE
STARTED

IF PRESCRIBED, NAME
OF HEALTH CARE
PROFESSIONAL

SIDE EFFECT(S)

4) Have you visited an emergency room for seizures? If so, when and where?
______________________________________________________________________________
______________________________________________________________________________
5) If you have seen any health care professionals for your seizures since you filed your claim,
complete the chart below.
NAME OF HEALTH CARE
PROFESSIONAL

ADDRESS AND PHONE NUMBER

DATE OF LAST
VISIT AND NEXT
SCHEDULED
APPOINTMENT
(IF ANY)

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

ADDRESS AND PHONE NUMBER

PHONE NUMBER

_________________________________________
Name of person completing this form (Please print)

____________ ___________________
Date
Phone

_________________________________________
Address

____________ ________
City
State

[Paperwork Reduction Act]

________
ZIP

Seizure Questionnaire Witness

Form Approved
OMB No. 0960-0555
[Standard Header]
Individual Name: {clmt_full_name}

{barcode}
PLEASE COMPLETE AND RETURN BY {third_party_form_return_date}
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.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________
Name of person completing this form (Please print)

____________ ___________________
Date
Phone

_________________________________________
Address

____________ ________
City
State

________
ZIP

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 Notices
(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.