Neck Disability Index form
This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please check off the answer that best applies:
Please rate your pain level with activity:
*
0= No Pain, 10 = Very Severe Pain
Pain Intensity
*
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worse imaginable at the moment
Personal Care (washing, dressing, etc)
*
I can look after myself normally without extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but manage most of my personal care
I need help every day in most aspects of self care
I cannot get dressed, wash with difficulty, and stay in bed
Lifting
*
I can lift heavy weights without extra pain
I can lift heavy weights but it gives me extra pain
Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table
Pain prevents me from lifting heavy weights but I can manage if they are conveniently placed
I can lift only very light weights
I cannot lift or carry anything at all
Headache
*
I have no headaches at all
I have slight headaches which come infrequently
I have moderate headaches which come infrequently
I have moderate headaches which come frequently
I have severe headaches which come infrequently
I have headaches almost all the time
Recreation
*
I am able to engage in all my recreational activities without pain
I am able to engage in my recreational activities with some pain
I am able to engage in most but not all of my usual recreational activities because of my neck pain
I am able to engage in a few of my usual recreational activities with some neck pain
I can hardly do any recreational activities because of neck pain
I can't do any recreational activities at all
Reading
*
I can read as much as I want with no pain in my neck
I can read as much as I want with slight neck pain
I can read as much as I want with moderate neck pain
I can't read as much as I want because of moderate neck pain
I can hardly read at all because of severe neck pain
I cannot read at all because of neck pain
Work
*
I can do as much as I want to
I can only do my usual work but no more
I can do most of my usual work but no more
I cannot do my usual work
I can hardly do any usual work at all
I can't do any work at all
Sleeping
*
Pain does not prevent me from sleeping well
My sleep is slightly disturbed (
My sleep is mildly disturbed (1-2 hr. sleep loss)
My sleep is moderately disturbed (2-3 hr. sleep loss)
My sleep is greatly disturbed (3-4 hr. sleep loss)
My sleep is completely disturbed (5-7 hr. sleep loss)
Concentration
*
I can concentrate fully when I want with no difficulty
I can concentrate fully when I want with slight difficulty
I have a fair degree of difficulty concentrating when I want
I have a lot of difficulty concentrating when I want
I have great difficulty concentrating when I want
I cannot concentrate at all
Driving
*
I can drive my car without neck pain
I can drive my car as long as I want with slight neck pain.
I can drive my car as long as I want with moderate neck pain.
I can't drive my car as long as I want because of moderate pain.
I can hardly drive my car at all because of severe neck pain.
I can't drive my car at all.
Physical Therapist:
Please Select
Dr. Patrick Buckley
Dr. Emily Nedley
Dr. Brittany Buckley
If you don't know your physical therapist, please leave it blank.
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