Brief Pain Inventory

Please take a few moments to answer the questions as honestly as you can. Your responses will help your care team assess your pain and tailor a treatment plan that works best for you.

First Name *

Last Name *

Email *

Date of Birth

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? *

Yes

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

Clear

Rate your pain levels below, where 0 is no pain and 10 is pain as bad as you can imagine

What best describes your pain at its WORST in the last week

0 1 2 3 4 5 6 7 8 9 10

What best describes your pain at its LEAST in the last week

0 1 2 3 4 5 6 7 8 9 10

What best describes your pain on AVERAGE

0 1 2 3 4 5 6 7 8 9 10

What best describes how much pain you have RIGHT NOW

0 1 2 3 4 5 6 7 8 9 10

Rate how much relief was provided, where 0 is no relief and 10 is complete relief

In the last week, how much RELIEF have pain treatments or medications provided?

0 1 2 3 4 5 6 7 8 9 10

Where 0 is does not interfere and 10 is completely interferes, describe how, during the past week, PAIN HAS INTERFERED with your:

Daily Schedule

0 1 2 3 4 5 6 7 8 9 10

Mood

0 1 2 3 4 5 6 7 8 9 10

Walking Ability

0 1 2 3 4 5 6 7 8 9 10

Normal Work (incl. both outside home & housework)

0 1 2 3 4 5 6 7 8 9 10

Relationships with other people

0 1 2 3 4 5 6 7 8 9 10

Sleep

0 1 2 3 4 5 6 7 8 9 10

Enjoyment of life

0 1 2 3 4 5 6 7 8 9 10

0.00