Neck Disability Index Questionnaire Template
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2Name__________________________ Date____________ Patient # _____________
Neck Disability Index
This questionnaire is designed to enable us to understand how much your neck pain
has affected your ability to manage everyday activities. Please answer each Section by
“checking” the ONE CHOICE that most applies to you. We realize that you may feel
that more than one statement may relate to you, but please just check the one choice
which closely describes your problem right now.
Section 1 - Pain intensity
O I have no pain at the moment.
O The pain is very mild at the moment.
O The pain is moderate at the moment.
O The pain is fairly severe at the moment.
O The pain is very severe at the moment.
O The pain is the worst imaginable at the moment.
Section 2 - Personal Care (Washing, Dressing, etc.)
O I can look after myself normally without causing extra pain.
O I can look after myself normally but it causes extra pain.
O It is painful to look after myself and I am slow and careful.
O I need some help but manage most of my personal care.
O I need help everyday in most aspects of self care.
O I do not get dressed; I wash with difficulty and stay in bed.
Section 3 - Lifting
O I can lift heavy weights without extra pain.
O I can lift heavy weights but it causes extra pain.
O Pain prevents me from lifting heavy weights off the floor, but I can manage if they are
conveniently positioned, for example, on a table.
O Pain prevents me from lifting heavy weights but I can manage light to medium weights if
they are conveniently positioned.
O I can lift only very light weights.
O I cannot lift or carry anything at all.
Section 4 - Reading
O I can read as much as I want to with no pain in my neck.
O I can read as much as I want to with slight pain in my neck.
O I can read as much as I want with moderate pain in my neck.
O I cannot read as much as I want because of moderate pain in my neck.
O I can hardly read at all because of severe pain in my neck.
O I cannot read at all.
Section 5 - Headaches
O I have no headaches at all.
O I have slight headaches which come infrequently.
O I have moderate headaches which come infrequently.
O I have moderate headaches which come frequently.
O I have severe headaches which come frequently.
O I have headaches almost all the time.
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