Basic Pain Inventory (BPI)

For any questions please contact us at info@midispensary.com.au or call 1300 MI TIME (1300 648 463).

Patient Details

Title *

First Name *

Last Name *

Date of Birth *

Gender *

Contact Number *Please include the area code if you are inputting a home phone number.

BPI Questionnaire

Instructions – Please read each question and then select one of the options to indicate the most accurate representation of your current pain levels.

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? *

YesNo

2. On the diagram, shade in the areas where you feel pain.

Put an X on the area(s) that hurts the most.

Basic Pain Assesment *

Clear drawing

Please list the area(s) where you experience the most pain – *

7. What treatments or medications are you receiving for your pain? *

9. Click the one number that describes how, during the past 24 hours PAIN HAS INTERFERED with your –

10. What do you believe was the original cause of the pain you are experiencing? *

11. How long have you been experiencing this pain? *

Thank you for submitting your answers, our MiDispensary practitioners will discuss your answers with you in your next appointment.

I declare all answers provided herein are true and accurate to the best of my knowledge and belief.

Patient Full Name

Date

Patient Signature

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