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Copyright 1991 Charles S. Cleeland, PhDPain Research GroupAll rights reservedPLEASE USEBLACK INK PENSubject's Initials : ________________PI: ________________________________________ Protocol #: _________________________________Study Name: ________________________________________ ___________________________________Revis ion: 07/01/05PI: ________________________________________ Protocol #: _________________________________Study Name: ________________________________________ ___________________________________Revis ion: 07/01/05(month)(day)(year)(month)(day)(y ear) Date: Study Subject #: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 everyday kinds of pain today?Brief Pain Inventory (Short Form)2. On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the Please rate your pain by marking the box beside the number that best describes your pain at its least in the last 24 Please rate your pain by marking the box beside the number that tells how much pain you have right Please rate your pain by marking the box beside the number that best describes your pain at its worst in the last 24 Please rate your pain by marking the box beside the number that best describes your pain on the 1 of 2 Copyright 1991 Charles S.
Copyright 1991 Charles S. Cleeland, PhD Pain Research Group All rights reserved PLEASE USE BLACK INK PEN Subject's Initials : _____ PI: _____
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