STUDY ID #:_ _ _ _ _ _ _ _ _ _ DO NOT WRITE ABOVE THIS LINE HOSPITAL #: _ _ _ _ _ _ _ _ _ _

Brief Pain Inventory (Short Form)

Date: _ _ _ _ / _ _ _ _ / _ _ _ _ Time: _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ ______________
Last First Middle Initial

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 every-
day 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.
Front Back
Right Left Left Right

E
L
P
M
A
S
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 as bad as
Pain 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 as bad as
Pain you can imagine
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 as bad as
Pain 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 as bad as
Pain you can imagine

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STUDY ID #:_ _ _ _ _ _ _ _ _ _ DO NOT WRITE ABOVE THIS LINE HOSPITAL #: _ _ _ _ _ _ _ _ _ _
Date: _ _ _ _/ _ _ _ _ / _ _ _ _ Time: _ _ _ _ _ _ _ _
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___________________ ______________
Last First Middle Initial

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 Complete
Relief Relief
9. Circle the one number that describes how, during the past 24 hours, pain has

E
interfered with your:
A. General Activity

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

P
Interfere Interferes
B. Mood

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

A
Interfere Interferes
C. Walking Ability

S
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere 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 Completely
Interfere Interferes
E. Relations with other people
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere Interferes
F. Sleep
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere Interferes
G. Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
Interfere Interferes
Copyright 1991 Charles S. Cleeland, PhD
Pain Research Group
All rights reserved

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