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Brief Pain Inventory (BPI) (Short Form)

Brief Pain Inventory (BPI) (Short Form) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


NM#800041 Worksheet Only – Not a Medical Record Document Page 1 of 2

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
BRIEF PAIN INVENTORY (SHORT FORM)




1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and
toothaches). Have you had pain other than these everyday kinds of pain today?
1. Yes 2. No
2. On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most.


3. Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.
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 at its least in the last 24 hours.
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 theone number that best describes your pain on the average.
0 1 2 3 4 5 6 7 8 9 10
No
Pain
Pain as bad as
you can imagine
6. 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





Front Back
Right Left Right Left


Patient Name

DOB:

MR #


NM#800041 Worksheet Only – Not a Medical Record Document Page 2 of 2

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
BRIEF PAIN INVENTORY (SHORT FORM)





7. What treatments or medications are you receiving for your pain?
____________________________________________________________________________________________
____________________________________________________________________________________________
8. In the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one
percentage that most shows how much relief you have received.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No
Relief
Complete
Relief
9. Circle the one number that describes how, during the past 24 hours, 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
Does not
Interfere
Completely
Interferes
C. Walking Ability
0 1 2 3 4 5 6 7 8 9 10
Does not
Interfere
Completely
Interferes
D. Normal Work (includes both work outside the home and housework)
0 1 2 3 4 5 6 7 8 9 10
Does not
Interfere
Completely
Interferes
E. Relations with other people
0 1 2 3 4 5 6 7 8 9 10
Does not
Interfere
Completely
Interferes
F. Sleep
0 1 2 3 4 5 6 7 8 9 10
Does not
Interfere
Completely
Interferes
G. Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
Does not
Interfere
Completely
Interferes
Copyright 1991 Charles S. Cleeland, PhD
Pain Research Group
All rights reserved