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Brief Pain Inventory Assessment Tool

This document contains the Brief Pain Inventory, a questionnaire used to assess a patient's pain severity and how it interferes with daily functions. It asks patients to rate their pain at its worst, least, and on average in the last week on a scale of 0-10. It also asks how pain interferes with general activity, mood, walking, work, relationships, sleep, and enjoyment of life. Scoring instructions are provided to calculate an overall pain severity score and pain interference score out of 10.

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Perdana Sihite
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386 views2 pages

Brief Pain Inventory Assessment Tool

This document contains the Brief Pain Inventory, a questionnaire used to assess a patient's pain severity and how it interferes with daily functions. It asks patients to rate their pain at its worst, least, and on average in the last week on a scale of 0-10. It also asks how pain interferes with general activity, mood, walking, work, relationships, sleep, and enjoyment of life. Scoring instructions are provided to calculate an overall pain severity score and pain interference score out of 10.

Uploaded by

Perdana Sihite
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Office Use Only

Date of Analysis: ____________________

MRN: _____________________________

Hunter Integrated Pain Service Pain Severity: ________________

Brief Pain Inventory Pain Interference: ________________


Dec 2006
Reproduced with acknowledgement of the Pain Research Group
The University of Texas MD Anderson Cancer Center, USA

Date: ___________________________

Name: ___________________________

1. On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts most.

2. Please rate your pain by circling the one number that best describes your pain at its worst in the last week.

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as you can imagine

3. Please rate your pain by circling the one number that best describes your pain at its least in the last week.

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as you can imagine

4. Please rate your pain by circling the one number that best describes your pain on average.

0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as you can imagine

5. Please rate your pain by circling the one number that tells how much pain you have right now.
0 1 2 3 4 5 6 7 8 9 10
No pain Pain as bad as you can imagine

6. What treatments or medications are you receiving for your pain?


_________________________________________________________________________________________

_________________________________________________________________________________________

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7. In the last week, how much relief have pain treatments or medications provided? Please circle the one percentage that
best shows how much relief you have received.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No relief Complete relief

8. Circle the one number that describes how, during the past week, pain has interfered with your:

a. General activity

0 1 2 3 4 5 6 7 8 9 10
Does not interfere Completely interferes

b. Mood

0 1 2 3 4 5 6 7 8 9 10

c. Walking ability

0 1 2 3 4 5 6 7 8 9 10

d. Normal work (includes both outside the home and housework)

0 1 2 3 4 5 6 7 8 9 10

e. Relations with other people

0 1 2 3 4 5 6 7 8 9 10

f. Sleep

0 1 2 3 4 5 6 7 8 9 10

g. Enjoyment of life

0 1 2 3 4 5 6 7 8 9 10

Does not interfere Completely interferes

Brief Pain Inventory Scoring Instructions

1. Pain Severity Score


This is calculated by adding the scores for questions 2, 3, 4 and 5 and then dividing by 4. This gives a severity score out of 10.

2. Pain Interference Score


This is calculated by adding the scores for questions 8a, b, c, d, e, f and g and then dividing by 7. This gives an interference
score out of 10.

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