BRIEF PAIN INVENTORY RESULT

Date: [Date]
Patient: [Name or ID, age]
Pain problem: [Diagnosis and main pain site]
Form: [Short form or long form, licensed copy; language]
How completed: [Self-completed on paper or tablet, or read aloud in an interview; interpreter if used]

SEVERITY, EACH 0 TO 10
Worst, last 24 hours: [Rating]
Least, last 24 hours: [Rating]
Average: [Rating]
Right now: [Rating]
Mean severity: [Mean of the four, one decimal]
Worst pain band: [No pain, mild, moderate, or severe]

INTERFERENCE, EACH 0 TO 10
General activity: [Rating]
Mood: [Rating]
Walking ability: [Rating]
Work, in or outside the home: [Rating]
Relations with other people: [Rating]
Sleep: [Rating]
Enjoyment of life: [Rating]
Mean interference: [Mean of the items answered, one decimal; needs 4 of 7]

BODY MAP AND TREATMENT
Areas shaded: [Sites, and where it hurts most]
Treatments now: [Medicines with doses and how often taken, and non-drug treatment]
Relief from treatment: [Percent, 0 to 100, over the last 24 hours]

CHANGE SINCE LAST BPI
Earlier results: [Date, worst pain, mean severity, mean interference]
Change: [Points and percent for each]
Meaningful: [Yes or no, and the threshold used]

ASSESSMENT
Function now: [What the patient can and cannot do, in their words]
Impression: [Cause of the pain, and what the scores add]

PLAN
Pain treatment: [Continue, adjust, start, or stop, with doses]
Activity and work: [Goals, pacing, and any limits]
Repeat BPI: [Date or interval]

Clinician: [Name, credentials]