BRIEF PAIN INVENTORY 1 2 3 4 5 6 Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Last Name:First Name:Middle Initial:Phone:Sex:MaleFemaleDate of Birth:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Status:SingleMarriedDivorcedSeparated/Divorced2) Education (Circle only the highest grade or degree completed): 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 M.A./M.S. Professional degree (please specify):3) Current occupation(specify titles;if you are not working, tell us your previous occupation):4) Spouse's occupation:5) Which of the following best describes your current job status? Employed outside the home, full-time Employed outside the home, part-time Homemaker Retired Unemployed Other 6) How long has it been since you first learned your diagnosis?(month/s)7) Have you ever had pain due to your present disease?YesNoUncertain8) When you first received your diagnosis, was pain one of your symptoms?YesNoUncertain9) Have you had surgery in the past month?YesNoWhat kind?10) Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, toothaches). Have you had pain other  than these everyday kinds of pain during the lastweek? YesNo10a) Did you take pain medications in the last 7 days?YesNo10b) I feel I have some form of pain now that requires medication each and every day.YesNoIF YOUR ANSWERS TO 10, 10a, AND 10b WERE  ALL NO, PLEASE STOP HERE AND GO TO THE LAST PAGE OF THE QUESTIONNAIRE AND SIGN WHERE INDICATED ON THE BOTTOM OF THE PAGE. IF ANY OF YOUR ANSWERS TO 10, 10a, AND 10b WERE YES, PLEASE CONTINUE. 11) Check all the areas where you feel pain: Abdomen Back Head Knee Neck Pelvic Shoulder Wrist & Hand 12) Please rate your pain by circling the one number that best describes your pain at its worst in the last week. 0 - No Pain, 10 - Pain as bad as you can imagine.01234567891013) Please rate your pain by circling the one number that best describes your pain at its least in the last week. 0 - No Pain, 10 - Pain as bad as you can imagine.01234567891014) Please rate your pain by circling the one number that best describes your pain on the average. 0 - No Pain, 10 - Pain as bad as you can imagine.01234567891015) Please rate your pain by circling the one number that tells how much pain you have right now. 0 - No Pain, 10 - Pain as bad as you can imagine.01234567891016) What kinds of things make your pain feel better (for example, heat, medicine, rest)?17) What kinds of things make your pain worse (for example, walking, standing, lifting)?18) What treatments or medications are you receiving for pain?19) In the last week, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received. 0% - No Relief, 100% - Complete Relief:0%10%20%30%40%50%60%70%80%90%100%20) If you take pain medication, how many hours does it take before the pain returns?1. Pain medication doesn't help at all2. One hour3. Two hours4. Three hours5. Four hours6. Five to twelve hours7. More than twelve hours8. I do not take pain medication21) Check the appropriate answer for each item. I believe my pain is due to:1. The effects of treatment (for example, medication, surgery, radiation, prosthetic device).YesNo2. My primary disease (meaning the disease currently being treated and evaluated).YesNo3. A medical condition unrelated to my primary disease (for example, arthritis). Please describe condition:YesNo 22) For each of the following words, check Yes or No if that adjective applies to your pain.AchingYesNoThrobbingYesNoShootingYesNoStabbingYesNoGnawingYesNoSharpYesNoTenderYesNoBurningYesNoExhaustingYesNoTiringYesNoPenetratingYesNoNaggingYesNoNumbYesNoMiserableYesNoUnbearableYesNo 23) Circle the one number that describes how, during the past week, pain has interfered with your: 0 - Does not interfere, 10 - Completely interferesA. General Activity012345678910B. Mood012345678910C. Walking Ability012345678910D. Normal Work (includes both work outside the home and housework)012345678910E. Relations with other people012345678910F. Sleep012345678910G. Enjoyment of life012345678910 24) I prefer to take my pain medicine:On a regular basisOnly when necessaryDo not take pain medicine25) I take my pain medicine (in a 24 hour period):Not every day1 to 2 times per day3 to 4 times per day5 to 6 times per dayMore than 6 times per day26) Do you feel you need a stronger type of pain medication?YesNoUncertain27) Do you feel you need to take more of the pain medication than your doctor has prescribed?YesNoUncertain28) Are you concerned that you use too much pain medication?YesNoUncertainWhy?29) Are you having problems with side effects from your pain medication?YesNoWhich side effects?30) Do you feel you need to receive further information about your pain medication?YesNo31) Other methods I use to relieve my pain include: (Please check all that apply): Warm compresses Cold compresses Relaxation techniques Distraction Biofeedback Hypnosis Other Please specify?32) Medications not prescribed by my doctor that I take for pain are:
