Patient: Age: Weight:

Brief Pain Inventory


Measure Pain and Function

BPI: Questionnaire for Pain and Function

Completed by:
Patient or Clinician

Purpose:
To screen for pain and how it interferes with function

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 during the last week?

Yes 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 checking the one number that best describes your pain at its worst in the last week.

0 1 2 3 4 5 6 7 8 9 10
No PainPain as bad as you can imagine

4. Please rate your pain by checking the one number that best describes your pain at its least in the last week.

0 1 2 3 4 5 6 7 8 9 10
No PainPain as bad as you can imagine

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

0 1 2 3 4 5 6 7 8 9 10
No PainPain as bad as you can imagine

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

0 1 2 3 4 5 6 7 8 9 10
No PainPain as bad as you can imagine

7. Are you receiving treatment or medication for your pain? Yes No

8. In the last week, how much relief have pain treatments or medications provided? Please check the one percentage that most shows how much relief you have received.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No ReliefComplete Relief

9. Check the one number that describes how much, during the past week, pain has interfered with your:

A. General Activity

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely Interferes

B. Mood

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely Interferes

C. Walking Ability

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely 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 InterfereCompletely Interferes

E. Relations with other people

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely Interferes

F. Sleep

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely Interferes

G. Enjoyment of life

0 1 2 3 4 5 6 7 8 9 10
Does Not InterfereCompletely Interferes

Pain Severity Score
Pain Interference Score
00

Scoring:
  • Pain Severity Score = Mean of items 3-6 (pain at its worst, pain at its least, average)
  • Pain Interference Score = Mean of items 9A-9G (interference of pain with: general activity, mood, walking, normal work, relations, sleep, enjoyment of life)

How to Interpret Score:
  • The higher the pain severity score, the more severe pain the patient feels they have
  • The higher the pain interference score, the more the patient feels their pain interferes with their activities of daily living

Reference: Tan, G., Jensen, M.P., Thornby, J.I., Shanti, B.F. (2004) Validation of the brief pain inventory for chronic nonmalignant pain. The Journal of Pain, 5(2), 133-137.

Link to Article: http://www.sciencedirect.com/science/article/pii/S1526590004000124

Reminder: choosing to 'Save' will save the entire eform and close this window.

Closing will not save your eform and any entered data will be lost.

Choosing to "Print All" will print this eform.

Line colour-thickness
thin thick