BriefBRIEF
PainPAIN
Inventory (Short Form)
Appendix: Multidimensional Pain Assessment Tools
INVENTORY (SHORT FORM)
Study ID# Hospital # 7) What treatments or medications are you receiving for your pain?
Do not write above this line.
Date:
Time:
8) In the past 24 hours, how much RELIEF have pain treatments or
medications provided? Please circle the one percentage that most
Name:
Last First Middle Initial shows how much relief you have received.
1) Throughout our lives, most of us have had pain from time to time 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No Complete
(such as minor headaches, sprains, and toothaches). Have you had Relief Relief
pain other than these everyday kinds of pain today?
9) Circle the one number that describes how, during the past 24 hours.
1. yes 2. no
PAIN HAS INTERFERED with your:
2) On the diagram, shade in the areas where you feel pain. Put an X on
the area that hurts the most. A. General Activity:
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere interferes
Right Left Left Right
B. Mood
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere interferes
C. Walking Ability
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere interferes
D. Normal work (Includes both work outside the home
3) Please rate your pain by circling the one number that best describes
and housework)
your pain at its WORST in the past 24 hours.
0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10
Does not Completely
No Pain as bad as
Interfere interferes
Pain you can imagine
4) Please rate your pain by circling the one number that best describes E. Relation with other people
your pain at its LEAST in the past 24 hours.
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10 Does not Completely
No Pain as bad as Interfere interferes
Pain you can imagine
F. Sleep
5) Please rate your pain by circling the one number that best describes
your pain on the AVERAGE. 0 1 2 3 4 5 6 7 8 9 10
Does not Completely
0 1 2 3 4 5 6 7 8 9 10 Interfere interferes
No Pain as bad as
Pain you can imagine G. Enjoyment of life
6) Please rate your pain by circling the one number that tell how much
pain you have RIGHT NOW. 0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere interferes
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad as
Pain you can imagine Copyright © 1991 Charles S. Cleeland, PhD
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