Brief Pain Inventory Brief Pain Inventory Your Name * Date of birth * Your GP * Please choose from list Dr Cash Dr Walls Dr Boyd Dr Calvert Dr MacSorley Dr Carswell Dr Duffy Dr Dickie Dr Mayson Dr Gilhespy Dr Popham ANP Claire Hill 1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these every-day kinds of pain today? * Yes No 2. Can you describe the areas where you feel pain, stating the area that hurts the most * 3. Please rate your pain by choosing the one number that best describes your pain at its WORST in the last 24 hours. * Please choose from the list 0 - No pain 1 2 3 4 5 6 7 8 9 10 - Pain as bad as you can imagine 4. Please rate your pain by choosing the one number that best describes your pain at its LEAST in the last 24 hours. * Please choose from the list 0 - No pain 1 2 3 4 5 6 7 8 9 10 - Pain as bad as you can imagine 5. Please rate your pain by choosing the one number that best describes your pain on the AVERAGE * Please choose from the list 0 - No pain 1 2 3 4 5 6 7 8 9 10 - Pain as bad as you can imagine 6. Please rate your pain by choosing the one number that tells how much pain you have RIGHT NOW * Please choose from the list 0 - No pain 1 2 3 4 5 6 7 8 9 10 - Pain as bad as you can imagine 7. What treatments or medications are you receiving for your pain? * 8. In the last 24 hours, how much relief have pain treatments or medications provided? Please choose the one percentage that most shows how much RELIEF you have received * Please choose from the list 0% - No relief 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% - Complete relief 9. Choose the one number that describes how, during the past 24 hours, pain has interfered with your: A. General Activity * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes B. Mood * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes C. Walking Ability * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes D. Normal Work (includes both work outside the home and housework) * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes E. Relations with other people * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes F. Sleep * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes G. Enjoyment of life * Please choose from the list 0 - Does not interfere 1 2 3 4 5 6 7 8 9 10 - Completely interferes CAPTCHA Submit If you are human, leave this field blank. Copyright 1991 Charles S. Cleeland, PhD Pain Research GroupAll rights reserved
