Pain

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?

Yes No

Please choose one before submitting.

2. On the diagram, choose the area that hurts the most.

Back Hand Arm Leg Feet

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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

Please choose one before submitting.

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

Please choose one before submitting.

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
No pain Pain as bad as you can imagine

Please choose one before submitting.

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

Please choose one before submitting.

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

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9. Choose 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

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B. Mood

0 1 2 3 4 5 6 7 8 9 10
Does not Interfere Completely Interferes

Please choose one before submitting.

C. Walking Ability

0 1 2 3 4 5 6 7 8 9 10
Does not Interfere Completely Interferes

Please choose one before submitting.

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

Please choose one before submitting.

E. Relations with other people

0 1 2 3 4 5 6 7 8 9 10
Does not Interfere Completely Interferes

Please choose one before submitting.

F. Sleep

0 1 2 3 4 5 6 7 8 9 10
Does not Interfere Completely Interferes

Please choose one before submitting.

G. Enjoyment of life

0 1 2 3 4 5 6 7 8 9 10
Does not Interfere Completely Interferes

Please choose one before submitting.

Agree to terms and conditions

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Pain

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?

2. On the diagram, choose 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.

4. Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours.

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

6. Please rate your pain by circling the one number that tells how much pain you have right now.

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.

9. Choose the one number that describes how, during the past 24 hours, pain has interfered with your:

A. General Activity

B. Mood

C. Walking Ability

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

E. Relations with other people

F. Sleep

G. Enjoyment of life