| bpi_date |
|
text |
Date |
|
| bpi_unusual_pain_yn |
|
yesno |
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 everyday kinds of pain today? |
1, Yes ; 0, No |
| bpi_pain_sites |
|
checkbox |
2) On the diagram shade the areas where you feel pain. |
1, face ; 2, back head ; 3, front left shoulder ; 4, front right shoulder ; 5, back left shoulder ; 6, back right shoulder ; 7, front left torso ; 8, front right torso ; 9, back left torso ; 10, back right torso ; 11, front left arm ; 12, front right arm ; 13, back left arm ; 14, back right arm ; 15, left hand ; 16, right hand ; 17, front left leg ; 18, front right leg ; 19, back left leg ; 20, back right leg ; 21, left foot ; 22, right foot ; 23, groin ; 24, left buttock ; 25, right buttock |
| bpi_worst |
|
radio |
3) Please rate your pain by circling the one number that best describes your pain at its WORST in the past 24 hours. |
0, 0 - No Pain ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - pain as bad as you can imagine |
| bpi_least |
|
radio |
4) Please rate your pain by circling the one number that best describes your pain at its LEAST in the past 24 hours. |
0, 0 - No Pain ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - pain as bad as you can imagine |
| bpi_average |
|
radio |
5) Please rate your pain by circling the one number that best describes your pain on the AVERAGE. |
0, 0 - No Pain ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - pain as bad as you can imagine |
| bpi_rightnow |
|
radio |
6) Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW. |
0, 0 - No Pain ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - pain as bad as you can imagine |
| bpi_treatments |
|
notes |
7) What treatments or medications are you receiving for your pain? |
|
| bpi_relief |
|
radio |
8) In the past 24 hours, how much RELIEF have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received. |
0, 0% - No relief ; 10, 10% ; 20, 20% ; 30, 30% ; 40, 40% ; 50, 50% ; 60, 60% ; 70, 70% ; 80, 80% ; 90, 90% ; 100, 100% - Complete relief |
| bpi_past24_general |
9) During the past 24 hours, pain has interfered with your: |
radio |
A. General activity |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_mood |
|
radio |
B. Mood |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_walking |
|
radio |
C. Walking ability |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_work |
|
radio |
D. Normal work (includes both work outside the home and housework) |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_relation |
|
radio |
E. Relations with other people |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_sleep |
|
radio |
F. Sleep |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |
| bpi_past24_enjoyment |
|
radio |
G. Enjoyment of life |
0, 0 - Does not interfere ; 1, 1 ; 2, 2 ; 3, 3 ; 4, 4 ; 5, 5 ; 6, 6 ; 7, 7 ; 8, 8 ; 9, 9 ; 10, 10 - Completely interferes |