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IBrief Pain Inventory
Liu, Qn Name 000 201 Stica9) 1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, toothaches). Have you had pain other than these everyday types of pain today?
Date 3010$I2019 Time 1010hcs
1
No
On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most.
Please rate your pain by circling the one number that best describes your pain at its worst in the past
24 hours. • 1 3 4
No pain
8 9 10 Pain as b,3d as yate (4n inTag
Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours.
0 1 No pain
3 4 5 6 7 0 9 10 Pain as bad as you uon inT.Rgine
Please rate your pain by circling the one number that best describes your pain on average.
O 1 2 pai’r1
.4 5 6 7 8 9 10 Pain AS NO 43 Jim; can imagine
Please rate your pain by circling the one number that tells how much pain you have right now
O 1 2 hto parr)
5 6 7 8 9 10 Pain 45 bad 45 yINI ran imagine
What treatment or medication are you receiving for the pain?
PDnQdal 05te_o 6(7 5 rn3 x Z TD5
In the past 24 hours, how much relief have pain treatments or medication provided? Please circle the one percentage that most shows how much relief you have received.
0% 10 20 30 AO 50 60 70 80 90 toff % No relief Conipiiete relief
Front
Circle the one number that describes how, during the past 24 hours, pain has interfered with your: A. General activity 2 3 0 5 7 8 9 10 Completely interferes
0 1 Do e5 not Interfere
B. Mood
0 1 2 Duel not interfere
4 5
;-1 7
8 9 10 Completely interferes
C.. Walking ability O 1 I 4 5 7 9 10 Does not ri ffi cu iii 1,3 to stDedl,erpreteiy Interfere # flterk-ms D. Normal work (includes both work outside the home and housework) NI iff 0 1 2 3 4 5 6 7 S 9 10 Does not Completely interfere interferes E. Relations with other people
O 1 2 3 4 5 6 J ▪ S 9 10 Does notcome I( interfere 1/4-I Completely interferes F. Sleep
0 Does not Interfere
I 2 3 p 5 6 7 . n at nhar
3 9 10 Completely interferes
G. Enjoyment of life O 1 G 3 4 5 Es 9 10 Does’ not Complete4e Interfere inter-ferias
H. Ability to concentrate
0 1 Does not J,1 to retire
I. Appetite
3 4 5 6
S 9 10 compfetely interferes
O 1 2 4 5 6 7 8 9 TO Doe5 not Compretei),0 ntertere sorneitimes forgers interferes I:Dec.010st of pDY)
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