Brief Pain Inventory Template (Short Form) - Modified Page 2
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1
2Please rate your pain by circling the one number that best describes your pain at its WORST in the past
24 hours.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that best describes your pain at its LEAST in the past
24 hours.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
Worst pain
No
0
1
2
3
4
5
6
7
8
9
10
you can
pain
imagine
In the last 24 hours, how much relief have your pain treatments or medications provided?
Please circle the one percentage that shows most how much RELIEF you have received.
No relief 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Complete relief
Circle the one number that describes how, during the past 24 hours, pain has interfered with your:
1. General Activity:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
2. Mood:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
3. Walking Ability:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
4. Normal Work (includes both work outside the home and housework)
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
5. Relations with other people:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
6. Sleep:
Does not interfere
0
1
2
3
4
5
6
7
8
9
10
Completely interferes
7. Enjoyment of Life:
Does not interfere
0
1
2
3
4
5
6
7
8 9
10
Completely interferes
With permission: Pain Research Group
MD Anderson Cancer Center, 1997
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Parent category: Medical