Umassmemorial Brief Pain Inventory (Short Form) Modified
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1
2PATIENT STAMP
Department of Family Medicine and Community
Health
Patient Pain Management Follow Up
Questionnaire
Brief Pain Inventory (Short Form) Modified
1.
Please rate your pain by marking the box beside the number that best describes your pain at its worst in the last 24
hours.
0
1
2
3
4
5
6
7
8
9
10
No
Pain As Bad As
Pain
You Can Imagine
2.
Please rate your pain by marking the box beside the 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
3.
Please rate your pain by marking the box beside the number that best describes 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
4.
In the last 24 hours, how much relief have pain treatments or medications provided? Please mark the box below
the percentage that most shows how much relief you have received?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
No
Complete
Relief
_________Relief __
5.
Mark the box beside the 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.
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
C.
Relations with other people
0
1
2
3
4
5
6
7
8
9
10
Does Not
Completely
Interfere
Interferes
FOR OFFICE USE ONLY: BPI TOTAL PAIN SCORE (Average #1, 2, 3 X 100)=_______
BPI TOTAL FUNCTIONAL SCORE (Average 5 A, B, C X 100)=______
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Parent category: Medical