BRIEF PAIN INVENTORY: SELF REPORT

The Purpose of this questionaire is to tell us about the severity of your pain and how the pain affects your day to day activities

Full Name

DOB

Phone

Completed by

Date

1. Throughout our lives, most of us have had had pain from time to time (such as minor headaches, sprains, and toothaches) Have you had pain other than these everyday kinds of pain?

YesNo

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

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3. Choose the words that best describe your pain.

Tingling NumbCrampingHeavyAchingShootingStabbingBurningDeep ThrobbingSharpExhaustingContinuousNaggingExcruciatingUnbearable

4. Please rate your pain by circling the one number that best describes your pain at its WORST in the past 24 hours.

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

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6. Please rate your pain by circling the one number that best describes your pain on AVERAGE.

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

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8. What treatments or medications are you receiving for your pain?

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

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10. Circle the one number that best describes how, during the past 24 hours, pain has interfered with your:

A. General activity

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B. Mood

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C. Walking ability

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

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E. Relations with other people

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F. Sleep

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G. Enjoyment of life

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11. Please choose any other symptoms that you may have.

NauseaIndigestionVomitingSweatingConstipationFeeling drowsyDiarrhea Tiredness Urinary problemsItching

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