Pain Chart #1

B1. Brief Pain Inventory (Short Form)
Study ID#_________________ Hospital#________________
Do not write above this line
Date:____/____/____
Time:______________
Name:______________________________________________________
Last First Middle Initial
1) 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?
1. yes 2. no
2) On the diagram, shade in the areas where you feel pain. Put
an X on the area that hurts the most.
3) Please rate your pain by circling the one number that best
describes your pain at its WORST in the past 24 hours.
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad as
pain you can imagine
_____________________________________________________________
4) Please rate your pain by circling the one number that best
describes your pain at its LEAST in the past 24 hours.
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad as
pain you can imagine
_____________________________________________________________
5) Please rate your pain by circling the one number that best
describes your pain on the AVERAGE.
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad as
pain you can imagine
_____________________________________________________________
6) 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 as bad as
pain you can imagine
_____________________________________________________________
7) What treatments or medications are you receiving for your
pain?
_____________________________________________________________
8) In the past 24 hours, how much RELIEF have pain treatments
or medications provided? Please circle the one percentage
that most shows how much.
_____________________________________________________________
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No Complete
relief relief
_____________________________________________________________

9) Circle the one number that describes how, during the past 24
hours, PAIN HAS INTERFERED with your:
A. General Activity:
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
B. Mood
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
C. Walking ability
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
D. Normal work (includes both work outside the home and
housework)
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
E. Relations with other people
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
F. Sleep
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
G. Enjoyment of life
_____________________________________________________________
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
_____________________________________________________________
For a Clearer copy of this chart go to: http://www.painworld.zip.com.au/downloads/pain_chart_1.html
Source: Pain Research Group, Department of Neurology, University of Wisconsin-Madison.
Used with permission. May be duplicated and used in clinical practice.




       

 

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Chart http://www.painworld.zip.com.au/downloads/pain_chart_1.html
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