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Multidimensional Pain Inventory
Patient Information
Name of Patient:
Date:

 

Instructions:
An important part of our evaluation includes examination of pain from your perspective. You know your pain better than anyone so the information you give us is very helpful in planning a treatment program for you.

Please read each question carefully and then do your best to answer each one. Try not to skip any questions.

After the last question, please use the blank text box add additional information that you think would be of help to us in better understanding your pain problem.
 

1. Rate the level of your pain at the present moment.
 No Pain
0
1
2
3
4
5
6		 Very Intense Pain 

2. In general, how much does your pain interfere with your day to day activities?

 No Interference
0
1
2
3
4
5
6		 Extreme Interference

3. Since the time your pain began, how much has your pain changed you ability to work?   Check here if you're not working for reasons other than your pain.

 No Change
0
1
2
3
4
5
6		 Extreme Change

4. How much has your pain changed the amount of satisfaction or enjoyment you get from taking part in social and recreational activities?

 No Change
0
1
2
3
4
5
6		 Extreme Change 

5. How supportive or helpful is your significant other to you in relation to your pain?

 Not Supportive
0
1
2
3
4
5
6		 Extremely Supportive

6. Rate your over-all mood during the past week.

 Extremely Low 
0
1
2
3
4
5
6		 Extremely High 

7. How much has your pain interfered with your ability to get enough sleep?

 No Interference
0
1
2
3
4
5
6		 Extreme Interference 

8. On the average, how severe has your pain been during the last week?

 Not Severe
0
1
2
3
4
5
6		 Extremely Severe  

9. How able are you to predict when your pain will start , get better or get worse?

 Not Able to Predict
0
1
2
3
4
5
6		 Very Able to Predict

10. How much has your pain changed your ability to take part in recreational and other social activities?

 No Change
0
1
2
3
4
5
6		  Extreme Change

11. How much do you limit your activities?

 Not at all
0
1
2
3
4
5
6		 Very Much

12. How much has your pain changed the amount of satisfaction or enjoyment you get from family related activities? 
 No Change
0
1
2
3
4
5
6		  Extreme Change

13. How worried is your spouse (or significant other) about you because of your pain?
 Not Worried at all
0
1
2
3
4
5
6		 Extremely Worried 

14. During the past week, how much control do you feel you have had over your life?
 No Control
0
1
2
3
4
5
6		 Extreme Control

15. On an average day how much does your pain vary? (increase or decrease)
 No Change
0
1
2
3
4
5
6		 Changes a lot 

16. How much suffering do you experience because of your pain?

 No Suffering
0
1
2
3
4
5
6		 Extreme Suffering 

17. How often are you able to do something to help to reduce your pain?

 Never
0
1
2
3
4
5
6		 Very Often 

18. How much has your pain changed your relationship with your spouse, family or significant other?

 No Change
0
1
2
3
4
5
6		 Extreme Change 

19. How much has your pain changed the amount of satisfaction or enjoyment you get from work? Check here if you are not presently working.

 No Change
0
1
2
3
4
5
6		 Extreme Change 

20. How attentive is your spouse to you because of your pain?

 Not Attentive
0
1
2
3
4
5
6		 Extremely Attentive 

21. During the past week, how well do you feel you’ve been able to deal with your problems?

 Not at All
0
1
2
3
4
5
6		 Extremely Well 

22. How much control do you feel you have over your pain?

 No Control At All
0
1
2
3
4
5
6		 Great Deal of Control 

23. How much has your pain changed your ability to do household chores?

 No Change
0
1
2
3
4
5
6		 Extreme Change 

24. During the past week, how successful were you in coping with stressful situations in your life?

 Not at all Successful
0
1
2
3
4
5
6		 Extremely Successful 

25. How much has your pain interfered with your ability to plan activities?

 No Interference
0
1
2
3
4
5
6		 Extreme Interference 

26. During the past week how irritable have you been?

 Not Irritable at all
0
1
2
3
4
5
6		 Extremely Irritable 

27. How much has your pain changed your friendships with people other than your family?

 No Change
0
1
2
3
4
5
6		 Extreme Change 

28. During the past week how tense or anxious have you been?

 Not Tense/Anxious at all
0
1
2
3
4
5
6		 Extremely Tense/Anxious 

Section 2

In this section, we are interested in knowing how your spouse or significant other responds to you when he or she knows you are in pain. On the scale listed below each question, circle a number to indicate how often your spouse responds to you in that particular way when you are in pain.
PLEASE ANSWER ALL OF THE 14 QUESTIONS.

1. Ignores me.

 Never
0
1
2
3
4
5
6		 Very Often 

2. Asks me what he or she can do to help.

 Never
0
1
2
3
4
5
6		 Very Often 

3. Reads to me.

 Never
0
1
2
3
4
5
6		 Very Often 

4. Gets irritated with me.

 Never
0
1
2
3
4
5
6		 Very Often 

5. Takes over my jobs or duties

 Never
0
1
2
3
4
5
6		 Very Often 

6. Talks to me about something else to take my mind off the pain

 Never
0
1
2
3
4
5
6		 Very Often 

7. Gets frustrated with me.

 Never
0
1
2
3
4
5
6		 Very Often 

8. Tries to get me to rest.

 Never
0
1
2
3
4
5
6		 Very Often 

9. Tries to involve me in some activity.

 Never
0
1
2
3
4
5
6		 Very Often 

10. Gets angry with me.

 Never
0
1
2
3
4
5
6		 Very Often 

11. Gets me pain medication.

 Never
0
1
2
3
4
5
6		 Very Often 

12. Encourages me to work on a hobby.

 Never
0
1
2
3
4
5
6		 Very Often 

13. Gets me something to drink.

 Never
0
1
2
3
4
5
6		 Very Often 

14. Turns on the T.V. to take my mind off my pain.

 Never
0
1
2
3
4
5
6		 Very Often 

SECTION 3

Listed below are 19 daily activities. Please indicate how often you do each of these by circling a number on the scale listed below each activity. 
PLEASE ANSWER ALL OF THE 19 QUESTIONS.

1. Wash dishes.

 Never
0
1
2
3
4
5
6		 Very Often 

2. Mow the lawn.

 Never
0
1
2
3
4
5
6		 Very Often 

3. Go out to eat.

 Never
1
2
3
4
5
6		 Very Often 

4. Play cards or other games.

 Never
0
1
2
3
4
5
6		 Very Often 

5. Go grocery shopping.

 Never
0
1
2
3
4
5
6		 Very Often 

6. Work in the garden.  Check here if you do not have a garden.

 Never
0
1
2
3
4
5
6		 Very Often 

7. Go to a movie.

 Never
0
1
2
3
4
5
6		 Very Often 

8. Visit friends.

 Never
0
1
2
3
4
5
6		 Very Often 

9. Help with the house cleaning.

 Never
0
1
2
3
4
5
6		 Very Often 

10. Work on the car. Check here if you do not have a car.

 Never
0
1
2
3
4
5
6		 Very Often 

11. Take a ride in a car or bus.

 Never
0
1
2
3
4
5
6		 Very Often 

12. Visit relatives. Check here if you do not have relatives within 100km.

 Never
0
1
2
3
4
5
6		 Very Often 

13. Prepare a meal.

 Never
0
1
2
3
4
5
6		 Very Often 

14. Wash the car. Check here if you do not have a car.

 Never
0
1
2
3
4
5
6		 Very Often 

9. Help with the house cleaning.

 Never
0
1
2
3
4
5
6		 Very Often 

10. Work on the car. Check here if you do not have a car.

 Never
0
1
2
3
4
5
6		 Very Often 

11. Take a ride in a car or bus.

 Never
0
1
2
3
4
5
6		 Very Often 

12. Visit relatives. Check here if you do not have relatives within 100km.

 Never
0
1
2
3
4
5
6		 Very Often 

13. Prepare a meal.

 Never
0
1
2
3
4
5
6		 Very Often 

14. Wash the car. Check here if you do not have a car.

 Never
0
1
2
3
4
5
6		 Very Often 

15. Take a trip.

 Never
0
1
2
3
4
5
6		 Very Often 

16. Go to a park or beach.

 Never
0
1
2
3
4
5
6		 Very Often 

17. Do the laundry.

 Never
0
1
2
3
4
5
6		 Very Often 

18. Work on a needed household repair.

 Never
0
1
2
3
4
5
6		 Very Often 

19. Engage in sexual activities.

 Never
0
1
2
3
4
5
6		 Very Often 

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