BRIEF PAIN INVENTORY Please complete this form fully – QUESTION ANSWER 1 Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains and toothaches). YES / NO Have you had pain other than these every-day kinds of pain? 2 On the diagram, shade in the areas where you feel pain. Put SEE FOLLOWING PAGE FOR DIAGRAM an X on the area that hurts the most. 3 In the last 24 hours, rate your pain at its worst, between 0 and 10. (0 - no pain / 10 pain as bad as you can imagine) – 4 In the last 24 hours, rate your pain at its best, between 0 and 10. (0 - no pain / 10 pain as bad as you can imagine) – 5 On the average, rate your pain between 0 and 10. (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/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 you have received. relief (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 activities: (0 = does not interfere / 10 = completely interferes) A General activity B Mood C Walking ability D Normal work (includes work outside the home and housework) E Relations with other people F Sleep G Enjoyment of life S-LANSS Pain Score Leeds Assessment of Neuropathic Symptoms and Signs (self-completed):
BRIEF PAIN INVENTORY – Please complete this form fully 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? YES / NO 2 On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most. SEE FOLLOWING PAGE FOR DIAGRAM 3 In the last 24 hours, rate your pain at its worst, between 0 and 10. (0 - no pain / 10 – pain as bad as you can imagine) 4 In the last 24 hours, rate your pain at its best, between 0 and 10. (0 - no pain / 10 – pain as bad as you can imagine) 5 On the average, rate your pain between 0 and 10. (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/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 activities: (0 = does not interfere / 10 = completely interferes) A General activity B Mood C Walking ability D Normal work (includes work outside the home and housework) E Relations with other people F Sleep G Enjoyment of life S-LANSS Pain Score Leeds Assessment of Neuropathic Symptoms and Signs (self-completed):
ESSENTIAL-QUESTIONNAIRE.docx