Brief Pain Inventory简明疼痛量表.PDFVIP

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) ____________________