Get Fillable Brief Pain Inventory Short Form

PATIENT STAMP Department of Family Medicine and Community Health Patient Pain Management Follow Up Questionnaire Brief Pain Inventory Short Form Modified Please rate your pain by marking the box beside the number that best describes your pain at its worst in the last 24 hours. No Pain Pain As Bad As You Can Imagine now. In the last 24 hours how much relief have pain treatments or medications provided Please mark the box below the percentage that most shows how much relief you have received Relief Complete Relief Mark the box beside the number that describes how during the past 24 hours pain has interfered with your A. General activity Does Not Interfere B. Normal work includes both work outside the home and housework C. Relations with other people FOR OFFICE USE ONLY BPI TOTAL PAIN SCORE Average 1 2 3 X 100 BPI TOTAL FUNCTIONAL SCORE Average 5 A B C X 100 Patient Name DOB MR GOAL SETTING PROGRESS What goals have you worked on since we last met 1. How successful have you been Goal 1 1 not at all 2 somewhat 3 achieved What barriers do you need to work on to reach your goal if you haven t yet Goal 2 Goal 3 1 not at all Have not been able to work on goals so far. No Pain Pain As Bad As You Can Imagine now. In the last 24 hours how much relief have pain treatments or medications provided Please mark the box below the percentage that most shows how much relief you have received Relief Complete Relief Mark the box beside the number that describes how during the past 24 hours pain has interfered with your A. General activity Does Not Interfere B. Normal work includes both work outside the home and housework C. General activity Does Not Interfere B. Normal work includes both work outside the home and housework C. Relations with other people FOR OFFICE USE ONLY BPI TOTAL PAIN SCORE Average 1 2 3 X 100 BPI TOTAL FUNCTIONAL SCORE Average 5 A B C X 100 Patient Name DOB MR GOAL SETTING PROGRESS What goals have you worked on since we last met 1. Relations with other people FOR OFFICE USE ONLY BPI TOTAL PAIN SCORE Average 1 2 3 X 100 BPI TOTAL FUNCTIONAL SCORE Average 5 A B C X 100 Patient Name DOB MR GOAL SETTING PROGRESS What goals have you worked on since we last met 1. How successful have you been Goal 1 1 not at all 2 somewhat 3 achieved What barriers do you need to work on to reach your goal if you haven t yet Goal 2 Goal 3 1 not at all Have not been able to work on goals so far. No Pain Pain As Bad As You Can Imagine now. In the last 24 hours how much relief have pain treatments or medications provided Please mark the box below the percentage that most shows how much relief you have received Relief Complete Relief Mark the box beside the number that describes how during the past 24 hours pain has interfered with your A. General activity Does Not Interfere B. Normal work includes both work outside the home and housework C. Relations with other people FOR OFFICE USE ONLY BPI TOTAL PAIN SCORE Average 1 2 3 X 100 BPI TOTAL FUNCTIONAL SCORE Average 5 A B C X 100 Patient Name DOB MR GOAL SETTING PROGRESS What goals have you worked on since we last met 1.