Brief Pain Inventory简明疼痛量表.PDF

Figure 3-3: Brief Pain Inventory Brief Pain Inventory Date: ______________________ Name: ________________________________________________________________________________ LAST FIRST MIDDLE INITIAL Phone: ( ________ ) _________________________________________ Sex: ? Female ? Male Date of Birth: ________________________________________ 1 Marital Status (at present) 1. ? Single 3. ? Widowed 2. ? Married 4. ? Separated/Divorced 2 Education (Circle only the highest grade or degree completed) Grade 0 1 2 3 4 5 6 7 8 10 11 12 13 14 16 M.A./M.S. Professional degree (please specify) ______________________________ 9 3 Current occupation: _________________________________________________________________ (specify titles; if you are not working, tell us your previous occupation) 4 Spouse’s Occupation: _______________________________________________________________ 5 Which of the following best describes your current job status? ? 1. Employed outside the home, full-time ? 2. Employed outside the home, part-time ? 4. Retired ? 5. Unemployed ? 3. Homemaker ? 6. Other 6 How long has it been since you first learned your diagnosis? _____________ months 7 Have you ever had pain due to your present disease? 1. ? Yes 2. ? No 3. ? Uncertain 8 When you first received your diagnosis, was pain one of your symptoms? 1. ? Yes 2. ? No 3. ? Uncertain 9 Have you had surgery in the past month? 1. ? Yes 2. ? No 10 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 everyday kinds of pain during the last week? 1. ? Yes 2. ? No If you answered YES to the last question, please go on to question 11 and finish this questionnaire. If NO, you are finished with the questionnaire. Thank you. 11 On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most. FRONT BACK Continue on next page. Figure 3-3: Brief Pain Inventory (continued) 26 picas Brief Pain Inventory continued 12