"Brief Pain Inventory Assessment Template - Hunter Integrated Pain Service"

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Date of Analysis: ____________________
MRN: _____________________________
Hunter Integrated Pain Service
Pain Severity:
________________
Brief Pain Inventory
Pain Interference:
________________
Dec 2006
Reproduced with acknowledgement of the Pain Research Group
The University of Texas MD Anderson Cancer Center, USA
Date:
___________________________
Name: ___________________________
1.
On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts most.
2. Please rate your pain by circling the one number that best describes your pain at its worst in the last week.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
3. Please rate your pain by circling the one number that best describes your pain at its least in the last week.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
4. Please rate your pain by circling the one number that best describes your pain on average.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
5. Please rate your pain by circling the one number that tells how much pain you have right now.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
6. What treatments or medications are you receiving for your pain?
_________________________________________________________________________________________
_________________________________________________________________________________________
Page 1 of 2
Office Use Only
Date of Analysis: ____________________
MRN: _____________________________
Hunter Integrated Pain Service
Pain Severity:
________________
Brief Pain Inventory
Pain Interference:
________________
Dec 2006
Reproduced with acknowledgement of the Pain Research Group
The University of Texas MD Anderson Cancer Center, USA
Date:
___________________________
Name: ___________________________
1.
On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts most.
2. Please rate your pain by circling the one number that best describes your pain at its worst in the last week.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
3. Please rate your pain by circling the one number that best describes your pain at its least in the last week.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
4. Please rate your pain by circling the one number that best describes your pain on average.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
5. Please rate your pain by circling the one number that tells how much pain you have right now.
0
1
2
3
4
5
6
7
8
9
10
No pain
Pain as bad as you can imagine
6. What treatments or medications are you receiving for your pain?
_________________________________________________________________________________________
_________________________________________________________________________________________
Page 1 of 2
7. In the last week, how much relief have pain treatments or medications provided? Please circle the one percentage that
best shows how much relief you have received.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No relief
Complete relief
8. Circle the one number that describes how, during the past week, pain has interfered with your:
a. General activity
0
1
2
3
4
5
6
7
8
9
10
Does not interfere
Completely interferes
b. Mood
0
1
2
3
4
5
6
7
8
9
10
c. Walking ability
0
1
2
3
4
5
6
7
8
9
10
d. Normal work (includes both outside the home and housework)
0
1
2
3
4
5
6
7
8
9
10
e. Relations with other people
0
1
2
3
4
5
6
7
8
9
10
f.
Sleep
0
1
2
3
4
5
6
7
8
9
10
g. Enjoyment of life
0
1
2
3
4
5
6
7
8
9
10
Does not interfere
Completely interferes
Brief Pain Inventory Scoring Instructions
1. Pain Severity Score
This is calculated by adding the scores for questions 2, 3, 4 and 5 and then dividing by 4. This gives a severity score out of 10.
2. Pain Interference Score
This is calculated by adding the scores for questions 8a, b, c, d, e, f and g and then dividing by 7. This gives an interference
score out of 10.
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