Brief Pain Inventory

Brief Pain Inventory

Please complete the form below.

First Name *

Last Name *

Date of birth *

Address *

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 everyday kinds of pain today? *

YesNo

On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most. *

Clear drawing

Please rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours *

0 (No Pain)12345678910 (Pain as bad as you can imagine)

Please rate your pain by selecting the one number that best describes your pain at its LEAST in the past 24 hours *

0 (No Pain)12345678910 (Pain as bad as you can imagine)

Please rate your pain by selecting the one number that best describes your pain on the AVERAGE *

0 (No Pain)12345678910 (Pain as bad as you can imagine)

Please rate your pain by selecting the one number that tell how much pain you have RIGHT NOW *

0 (No Pain)12345678910 (Pain as bad as you can imagine)

What treatments or medications are you receiving for your pain? *If NONE, please enter none.

In the past 24 hours, how much RELIEF have pain treatments or medications provided? Please select the one percentage that most shows how much relief you have received. *

0 (No relief)102030405060708090100 (Complete relief)

Select the one number that describes how, during the past 24 hours. PAIN HAS INTERFERED with your: *