Brief Pain Inventory (Short Form)

1 Appendix: Multidimensional pain Assessment ToolsStudy ID# Hospital #Do not write above this :Time:Name:LastFirstMiddle Initial1)Throughout our lives, most of us have had pain from time to time(such as minor headaches, sprains, and toothaches). Have you hadpain other than these everyday kinds of pain today?1. yes2. no2) On the diagram, shade in the areas where you feel pain . Put an X onthe area that hurts the ) Please rate your pain by circling the one number that best describesyour pain at its WORSTin the past 24 as bad asPainyou can imagine4) Please rate your pain by circling the one number that best describesyour pain at its LEASTin the past 24 as bad asPainyou can imagine5) Please rate your pain by circling the one number that best describesyour pain on the as bad asPainyou can imagine6)

2 Please rate your pain by circling the one number that tell how muchpain you have RIGHT as bad asPainyou can imagineRight LeftLeft Right7) What treatments or medications are you receiving for your pain ? 8) In the past 24 hours, how much RELIEF have pain treatments or medications provided? Please circle the one percentage that mostshows how much relief you have 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%NoCompleteReliefRelief9) Circle the one number that describes how, during the past 24 HAS INTERFERED with your: A.

3 General Activity:012345678910 Does notCompletelyInterfereinterferesB. Mood012345678910 Does notCompletelyInterfereinterferesC. Walking Ability012345678910 Does notCompletelyInterfereinterferesD. Normal work (Includes both work outside the home and housework)012345678910 Does notCompletelyInterfereinterferesE. Relation with other people012345678910 Does notCompletelyInterfereinterferesF. Sleep012345678910 Does notCompletelyInterfereinterferesG. Enjoyment of life012345678910 Does notCompletelyInterfereinterferesCopyrigh t 1991 Charles S.

4 Cleeland, PhDBRIEF pain Inventory (SHORT FORM) Brief pain Inventory (Short Form)