Brief Pain Inventory Short Form - The University Of Texas Md Anderson Cancer Center
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1
2BRIEF PAIN INVENTORY
7) What treatments or medications are you
Date
/
/
Time:
receiving for your pain?
________________________________________________
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
8) In the last 24 hours, how much relief have pain
everyday kinds of pain today?
treatments or medications provided? Please circle
the one percentage that shows how much RELIEF
1. Yes
2. No
you have received.
2) On the diagram, shade in the areas where you feel
0% 10 20 30 40
50
60
70 80 90 100%
pain. Put an X on the area that hurts the most.
No
Complete
relief
relief
Right
Left
Left
Right
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
3) Please rate your pain by circling the one number
that best describes your pain at its WORST in the
0
1
2
3
4
5
6
7
8
9
10
last 24 hours.
Does not
Completely
interfere
interferes
0
1
2
3
4
5
6
7
8
9
10
No
Pain as bad
D. Normal work (includes both work outside the
Pain
as you can
imagine
home and housework)
4) Please rate your pain by circling the one number
0
1
2
3
4
5
6
7
8
9
10
that best describes your pain at its LEAST in the
Does not
Completely
last 24 hours.
interfere
interferes
0
1
2
3
4
5
6
7
8
9
10
E. Relations with other people
No
Pain as bad
Pain
as you can
0
1
2
3
4
5
6
7
8
9
10
imagine
Does not
Completely
5) Please rate your pain by circling the one number
interfere
interferes
that best describes your pain on the AVERAGE.
0
1
2
3
4
5
6
7
8
9
10
F. Sleep
No
Pain as bad
0
1
2
3
4
5
6
7
8
9
10
Pain
as you can
Does not
Completely
imagine
interfere
interferes
6) Please rate your pain by circling the one number
that tells how much pain you have RIGHT NOW.
G. Enjoyment of life
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
No
Pain as bad
Does not
Completely
Pain
as you can
interfere
interferes
imagine
Brief Pain Inventory (Short Form). Source: Pain Research Group, Department of
Provided as an educational service by
Neuro-Oncology, The University of Texas MD Anderson Cancer Center.
Used with permission. Adapted to single page format.
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