Brief pain inventory

Brief Pain Inventory

1. Patient Details

Name*

First NameLast Name

Date of birth*

Date

Email

example@example.com

2. Pain Location

On the diagram, please shade the areas where you feel pain. Please mark an X on the most painful area.

(Please use the colour red on image)

3. Pain Severity

Please rate your pain below*

	0 No pain	1	2	3	4	5	6	7	8	9	10 Extremely painful
At it's worst over the last 24 hours
At it's least over the last 24 hours
On average
Currently

4. Pain Treatments and Medications

Have you received any treatments or medications for your pain:*

YesNo

What treatments and medications have you used.

Have they helped:

YesNo

5. How your pain affects you

Please rate how your pain affects you*

	0 does not interfere	1	2	3	4	5	6	7	8	9	10 Completely interferes
General activities
Mood
Normal work (outside home and housework)
Relations with other people
Sleep
Enjoyment of life

How confident are you that you can do the following things, despite your pain?*

	0 Not that confident	1	2	3	4	5	6 Extremely confident
Enjoy things
Do household chores
Socialise with friends and family
Cope in most situations
Do any form of work
Participate in hobbies and leisure activities
Accomplish goals in life
Live a normal lifestyle
Become active