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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 n....

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On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts most. Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.

The Brief Pain Inventory (BPI) rapidly assesses the severity of pain and its impact on functioning. The BPI has been translated into dozens of languages, and it is widely used in both research and clinical settings.

Worst Pain Score: 1 4 = Mild Pain. Worst Pain Score: 5 6 = Moderate Pain. Worst Pain Score: 7 10 = Severe Pain.

The BPI measures how much pain has interfered with seven daily activities, including general activity, walking, work, mood, enjoyment of life, relations with others, and sleep. BPI pain interference is typically scored as the mean of the seven interference items.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232