Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Brief Pain Inventory

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 everyday kinds of pain today?
  2. 1. Yes             2. No

  3. On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most.
  4. Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.
  5. 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 best describes your pain at its least in the last 24 hours.
  7. 0        1        2        3        4        5        6        7        8        9        10
    No                                                                                                Pain as bad as
    Pain                                                                                              you can imagine 

  8. Please rate your pain by circling the one number that best describes your pain on the average.
  9. 0        1        2        3        4        5        6        7        8        9        10
    No                                                                                                Pain as bad as
    Pain                                                                                              you can imagine

  10. Please rate your pain by circling the one number that tells how much pain you have right now.
  11. 0        1        2        3        4        5        6        7        8        9        10
    No                                                                                                Pain as bad as
    Pain                                                                                              you can imagine

  12. What treatments or medications are you receiving for your pain?
  13. _____________________________________________________

  14. 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.
  15. 0        1        2        3        4        5        6        7        8        9        10
    No                                                                                                Pain as bad as
    Pain                                                                                              you can imagine

  16. Circle the one number that describes how, during the past 24 hours, pain has interfered with your:
  17. A. General Activity

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

    B. Mood

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

    C. Walking Ability

    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

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Copyright 1991 Charles S. Cleeland, PhD, Pain Research Group. All rights reserved.