BRIEF PAIN INVENTORY

First name *

Surname *

Date of Birth *

Please choose your doctor *

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?

YesNo

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

Clear drawing

7) What treatments or medications are you receiving for your pain?

QA - G Please select the rating that best represents in the last 24hrs how your pain has interfered with-

Signature *

Draw signature|Type signatureClear

Date *

Pain Severity Score

Pain Interference

Pain Severity Score

Score range	Interpretation
0 - 0.99	No pain
1 - 3.99	Mild pain
4 - 6.99	Moderate pain
7 - 10	Severe pain

Pain Interference Score

Score range	Interpretation
0 - 0.99	No interference
1 - 3.99	Mild interference
4 - 6.99	Moderate interference
7 - 10	Severe interference