Patient Questionnaire Template - Upper Quarter And Cervical Spine (Page 4 of 4) in pdf

Neck Index

*PLEASE FILL OUT PRIOR TO YOUR APPOINTMENT*

ACN Group, Inc. Form NI-100

(Neck Disability Index)

ACN Group, Inc. Use Only rev 3/27/2003

Patient Name

Date

This questionnaire will give your provider information about how your neck condition affects your everyday life.

Please answer every section by marking the one statement that applies to you. If two or more statements in one

section apply, please mark the one statement that most closely describes your problem.

Pain Intensity

Personal Care

I have no pain at the moment.

I can look after myself normally without causing extra pain.

The pain is very mild at the moment.

I can look after myself normally but it causes extra pain.

The pain comes and goes and is moderate.

It is painful to look after myself and I am slow and careful.

The pain is fairly severe at the moment.

I need some help but I manage most of my personal care.

The pain is very severe at the moment.

I need help every day in most aspects of self care.

The pain is the worst imaginable at the moment.

I do not get dressed, I wash with difficulty and stay in bed.

Sleeping

Lifting

I have no trouble sleeping.

I can lift heavy weights without extra pain.

My sleep is slightly disturbed (less than 1 hour sleepless).

I can lift heavy weights but it causes extra pain.

My sleep is mildly disturbed (1-2 hours sleepless).

Pain prevents me from lifting heavy weights off the floor, but I can manage

My sleep is moderately disturbed (2-3 hours sleepless).

if they are conveniently positioned (e.g., on a table).

Pain prevents me from lifting heavy weights off the floor, but I can manage

My sleep is greatly disturbed (3-5 hours sleepless).

light to medium weights if they are conveniently positioned.

My sleep is completely disturbed (5-7 hours sleepless).

I can only lift very light weights.

I cannot lift or carry anything at all.

Reading

Driving

I can read as much as I want with no neck pain.

I can drive my car without any neck pain.

I can read as much as I want with slight neck pain.

I can drive my car as long as I want with slight neck pain.

I can read as much as I want with moderate neck pain.

I can drive my car as long as I want with moderate neck pain.

I cannot read as much as I want because of moderate neck pain.

I cannot drive my car as long as I want because of moderate neck pain.

I can hardly read at all because of severe neck pain.

I can hardly drive at all because of severe neck pain.

I cannot read at all because of neck pain.

I cannot drive my car at all because of neck pain.

Concentration

Recreation

I can concentrate fully when I want with no difficulty.

I am able to engage in all my recreation activities without neck pain.

I can concentrate fully when I want with slight difficulty.

I am able to engage in all my usual recreation activities with some neck pain.

I have a fair degree of difficulty concentrating when I want.

I am able to engage in most but not all my usual recreation activities because of neck pain.

I have a lot of difficulty concentrating when I want.

I am only able to engage in a few of my usual recreation activities because of neck pain.

I have a great deal of difficulty concentrating when I want.

I can hardly do any recreation activities because of neck pain.

I cannot concentrate at all.

I cannot do any recreation activities at all.

Work

Headaches

I can do as much work as I want.

I have no headaches at all.

I can only do my usual work but no more.

I have slight headaches which come infrequently.

I can only do most of my usual work but no more.

I have moderate headaches which come infrequently.

I cannot do my usual work.

I have moderate headaches which come frequently.

I can hardly do any work at all.

I have severe headaches which come frequently.

I cannot do any work at all.

I have headaches almost all the time.

Neck

Index

Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100

Score

Patient Questionnaire Template - Upper Quarter And Cervical Spine Page 4

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