Brief Pain Inventory Template (Short Form) - Modified

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Brief Pain Inventory (Short Form) - Modified
Name _________________________________________
Date
__________________________________
On the diagram below, colour in the areas where you feel pain. Label the most painful area with the
number 1, the second most painful with the number 2.(Black=sharp/stabbing, Red=burning,
Blue=numbness, Green=pins and needles, Yellow=aching, Arrows = shooting pain.
What things make your pain feel worse?
What things make your pain feel better?
What treatments or medications are you currently receiving for your pain:

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