Neck Pain And Disability Index
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1Neck Pain and Disability Index
Name: __________________________________ Chart #________________ Date:___________
Please Read Instructions:
This questionnaire has been designed to give the doctor information as to how your low back pain has affected your ability
to manage everyday life. In each section, please Check ONE Box which most closely describes your problem.
Section 1- Pain Intensity
Section 6 – Concentration
A. I have no pain at the moment
A. I can concentrate fully when I want with no difficulty.
B. The pain is mild at the moment.
B. I can concentrate fully when I want with slight difficulty.
C. The pain is moderate at the moment.
C. I have a fair degree of difficulty in concentrating when I want.
D. The pain is fairly severe at the moment.
D. I have a lot of difficulty in concentrating when I want.
E. The pain is very severe at the moment.
E. I have a great degree of difficulty in concentrating when I want
F. The pain is the worst imaginable at the moment.
F. I cannot concentrate at all
Section 2 – Personal Care
Section 7- Work
A. I can look after myself normally without causing extra pain
A. I can do as much work as I want.
B. I can look after myself normally but it causes extra pain
B. I can only do my usual work, but no more.
C. It is painful to look after myself and I am slow and careful.
C. I can do most of my usual work, but no more.
D. I need some help but manage most of my personal care.
D. I can hardly do any work at all.
E. I need help every day in most aspects of self care.
E. I cannot do my usual work.
F. I do not get dressed; I wash with difficulty and stay in bed.
F. I can’t do any work at all.
Section 3 – Lifting
Section 8 – Driving
A. I can read as much as I want with no pain in my neck.
A. I can drive my car without any neck pain.
B. I can lift heavy weight but it gives extra pain.
B. I can drive my car was long as I want with slight pain in my neck.
C. Pain prevents me from lifting heavy weights off the floor, but I
C. I can drive my car as long as I want with moderate pain.
can manage if they are conveniently positioned.
D. I can’t drive my car as long as I want because of moderate pain.
D. Pain prevents me from lifting heavy weights, but I can manage
E. I can’t drive my car al long as I want because of severe pain in my
light-medium weights if they are conveniently positioned.
neck.
E. I can lift very light weights.
F. I can’t drive my car at all.
F. I cannot lift or carry anything at all.
Section 4 –Reading
Section 9 – Sleeping
A. I can read as much as I want with no pain in my neck.
A. I have no trouble sleeping.
B. I can read as much as I want with slight pain in my neck.
B. My sleep is slightly disturbed (less than 1 hr. sleepless)
C. I can read as much as I want with moderate pain in my neck.
C. My sleep is mildly disturbed (2-3 hrs sleepless.)
D I can’t read read as much as I want because of severe pain in my
D. My sleep is greatly disturbed (3-5 hours sleepless)
in my neck.
E. My sleep is greatly disturbed (3-5 hrs. sleepless)
E. I can hardly read at all because of severe pain in my neck.
F. My sleep is completely disturbed (5-7 hrs. sleepless).
F. I can not read at all.
Section 10 – Changing Decree Of Pain
A. I am able to engage in all recreational activities with no neck pain.
Section 5- Headaches
B. I am able to engage in all my recreational activities, with some pain
A. I have no headaches at all.
in my neck.
B. I have slight headaches which come infrequently.
C. I am able to engage in most , but not all of my unusual recreational
C. I have moderate headaches which come infrequently.
activities because of pain in my neck.
D. I have moderate headaches which come frequently.
D. I can hardly do any recreational activities because of pain.
E. I have severe headaches which come frequently.
E. I can hardly do any recreational activities because of pain.
F. I have headaches almost all the time.
F. I can’t do any recreational activities at all.
Office Use Only
Score:_______
.
I understand that the information I have provided above is current and complete to the best of my knowledge
Signature:
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