Brief Pain Inventory

For completion by patients returning for review. To be completed by all returning patients. Please note; All clinical information that we hold regarding the assessment and treatment of our patients, for best practice purposes, is sent to patients' GPs so that primary care providers can see precisely what you have presented with and how we are treating you. Your medical history as described by you in this questionnaire forms the basis of the review with your Consultant and provides essential background information regarding your pain/condition, and as such it is sent to your GP with your clinic review letter.

    Question Answer
    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? YesNo
    2 Please tell us where you are feeling pain. E.G 'Lower back' or 'base of skull' etc. Note as many areas as needed.
    3 Please rate your pain by number that best describes your pain at its worst in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)
    4 Please rate your pain by number that best describes your pain at its least in the last 24 hours. (0 - no pain / 10 – pain as bad as you can imagine)
    5 Please rate your pain by number that best describes your pain on the average.
    (0 - no pain / 10 – pain as bad as you can imagine)
    6 Please rate your pain by number that tells how much pain you have right now.
    (0 - no pain / 10 – pain as bad as you can imagine)
    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 give a percentage that most shows how much relief you have received. (0% - no relief / 100% - complete relief)
    9 Indicate below the one number that describes how, during the past 24 hours, pain has interfered with your:
    (0- does not interfere / 10 – completely interferes)
    A General activity
    B Mood
    C Walking ability
    D Normal work (includes both work outside the home and housework)
    E Relations with other people
    F Sleep
    G Enjoyment of life

    Please note, all information given on this proforma remains confidential and is held securely by London Pain Clinic in accordance with the Data Protection Act 1998.The information is used to help simplify your assessment and to enable maximum time to be spent on examination and discussion during your assessment. It is no way a substitute for a full consultation and examination. Thank you for taking the time to complete this questionnaire.

    Please note that the outcome will be based on the information you have provided. Therefore, London Pain Clinic accepts no responsibility for advice/information given relating to any incomplete, inaccurate or incorrect information you have provided.