The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 3: Assessment of Physical SymptomsFigure 3-3: Brief Pain Inventory26 picasDate: ______________________Brief Pain InventoryIIIName: ________________________________________________________________________________LAST FIRST MIDDLE INITIALPhone: ( ________ ) _________________________________________ Sex: ❑ Female ❑ MaleDate of Birth: ________________________________________1 Marital Status (at present)1. ❑ Single 3. ❑ Widowed2. ❑ Married 4. ❑ Separated/Divorced2345678Education (Circle only the highest grade or degree completed)Grade 0 1 2 3 4 5 6 7 8 910 11 12 13 14 16 M.A./M.S.Professional degree (please specify) ______________________________Current occupation: _________________________________________________________________(specify titles; if you are not working, tell us your previous occupation)Spouse’s Occupation: _______________________________________________________________Which of the following best describes your current job status?❑ 1. Employed outside the home, full-time❑ 4. Retired❑ 2. Employed outside the home, part-time❑ 5. Unemployed❑ 3. Homemaker❑ 6. OtherHow long has it been since you first learned your diagnosis? _____________ monthsHave you ever had pain due to your present disease?1. ❑ Yes 2. ❑ No 3. ❑ UncertainWhen you first received your diagnosis, was pain one of your symptoms?1. ❑ Yes 2. ❑ No 3. ❑ Uncertain9 Have you had surgery in the past month? 1. ❑ Yes 2. ❑ No10 Throughout our lives, most of us have had pain from time to time (such as minorheadaches, sprains, and toothaches). Have you had pain other thanthese everyday kinds of pain during the last week? 1. ❑ Yes 2. ❑ NoIf you answered YES to the last question, please go on to question 11 and finish thisquestionnaire. If NO, you are finished with the questionnaire. Thank you.11On the diagram, shade in the areas where you feel pain. Put an X on the areathat hurts the most.FRONTBACKContinue on next page.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 69