Umassmemorial Brief Pain Inventory (Short Form) Modified (Page 2 of 2) in pdf

Umassmemorial Brief Pain Inventory (Short Form) Modified Page 2

Patient Name:_________________________ DOB:_______________________ MR#:_____________________

GOAL SETTING PROGRESS

What goals have you worked on since we last met?

1. __________________________________________________________________

2. __________________________________________________________________

3. _________________________________________________________________

How successful have you been?

Goal 1:

1= not at all

2=somewhat

3= achieved

What barriers do you need to work on to reach your goal if you haven’t yet?

Goal 2:

1= not at all

2=somewhat

3= achieved

What barriers do you need to work on to reach your goal if you haven’t yet?

Goal 3: 1= not at all

2=somewhat

3= achieved

What barriers do you need to work on to reach your goal if you haven’t yet?

□ Have not been able to work on goals so far.

What would you like to work on?

Goal #1:_____________________________________________________

Goal #2:_______________________________________________________

What are some steps you can take towards these goals?

Umassmemorial Brief Pain Inventory (Short Form) Modified Page 2