"Modified Brief Pain Inventory Short Form"

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Brief Pain Inventory (Short Form) - Modified
Name _________________________________________
Date
__________________________________
On the diagram below, colour in the areas where you feel pain. Label the most painful area with the
number 1, the second most painful with the number 2.(Black=sharp/stabbing, Red=burning,
Blue=numbness, Green=pins and needles, Yellow=aching, Arrows = shooting pain.
What things make your pain feel worse?
What things make your pain feel better?
What treatments or medications are you currently receiving for your pain:
Brief Pain Inventory (Short Form) - Modified
Name _________________________________________
Date
__________________________________
On the diagram below, colour in the areas where you feel pain. Label the most painful area with the
number 1, the second most painful with the number 2.(Black=sharp/stabbing, Red=burning,
Blue=numbness, Green=pins and needles, Yellow=aching, Arrows = shooting pain.
What things make your pain feel worse?
What things make your pain feel better?
What treatments or medications are you currently receiving for your pain:
Please rate your pain by circling the one number that best describes your pain at its WORST in the past
24 hours.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that best describes your pain at its LEAST in the past
24 hours.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
In the last 24 hours, how much relief have your pain treatments or medications provided?
Please circle the one percentage that shows most how much RELIEF you have received.
No relief 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Complete relief
Circle the one number that describes how, during the past 24 hours, pain has interfered with your:
1. General Activity:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
2. Mood:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
3. Walking Ability:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
4. Normal Work (includes both work outside the home and housework)
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
5. Relations with other people:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
6. Sleep:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
7. Enjoyment of Life:
Does not interfere
0
1
2
3
4
5
6
7
8 9
10
Completely interferes
With permission: Pain Research Group
MD Anderson Cancer Center, 1997
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