Brief Pain Inventory – Bruntsfield Medical Practice

Brief Pain Inventory

Your Name

Date of birth

Your GP

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

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.

4. Please rate your pain by choosing the one number that best describes your pain at its LEAST in the last 24 hours.

5. Please rate your pain by choosing the one number that best describes your pain on the AVERAGE

6. Please rate your pain by choosing the one number that tells how much pain you have RIGHT NOW

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

9. Choose the one number that describes how, during the past 24 hours, pain has interfered with your:

A. General Activity

B. Mood

C. Walking Ability

D. Normal Work (includes both work outside the home and housework)

E. Relations with other people

F. Sleep

G. Enjoyment of life

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