BRIEF PAIN INVENTORY

First name *

Surname *

Date of Birth *

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.

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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-

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Date *