Neck Pain And Disability Index Questionnaire Template
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1
2NECK PAIN AND DISABILITY INDEX
Patient Name:________________________________________________
Date:______/______/______
Please read instructions carefully.
This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage everyday life. Please
read all statements in each section and then mark the box that most closely describes your problem.
SECTION 1 - PAIN INTENSITY
SECTION 6 - CONCENTRATION
I have no pain at the moment.
I can concentrate fully when I want to with no difficulty.
The pain is very mild at the moment.
I can concentrate fully when I want to with slight difficulty.
The pain is moderate at the moment.
I have a fair degree of difficulty in concentrating when I want to.
The pain is fairly severe at the moment.
I have a lot of difficulty in concentrating when I want to.
The pain is very severe at the moment.
I have a great deal of difficulty in concentrating when I want to.
The pain is worse than imaginable at the moment.
I cannot concentrate at all.
SECTION 7 - WORK
SECTION 2 - PERSONAL CARE (washing, dressing,
etc.)
I can do as much work as I want.
I can do only my usual work, but no more.
I can look after myself normally without causing extra pain.
I can do most of my usual work, but no more.
I can look after myself normally but it causes extra pain.
I cannot do my usual work.
It is painful to look after myself and I am slow and careful.
I can hardly work at all.
I need some help but manage most of my personal care.
I can't do any work at all.
I need help every day in most aspects of self-care.
I do not get dressed. I wash with difficulty and stay in bed.
SECTION 8 - DRIVING
SECTION 3 - LIFTING
I can drive without any neck pain.
I can drive as long as I want with slight neck pain.
I can lift heavy objects without any extra pain.
I can drive as long as I want with moderate neck pain.
I can lift heavy objects, but it gives extra pain.
I can hardly drive at all because of severe neck pain.
Pain prevents me from lifting heavy objects off the floor but I can
I can't drive at all.
manage if they are conveniently positioned on a table.
Pain prevents me from lifting heavy objects but I can manage
SECTION 9 - SLEEPING
light to medium objects.
I can lift very light objects.
I have no trouble sleeping.
I cannot lift or carry anything at all.
My sleep is slightly disturbed (less than 1 hr. sleepless).
My sleep is mildly disturbed (1-2 hrs. sleepless).
SECTION 4 - READING
My sleep is moderately disturbed (3-5 hrs. sleepless).
My sleep is completely disturbed (5-7 hrs. sleepless).
I can read as much as I want to with no pain in my neck.
I can read as much as I want to with light pain in my neck.
SECTION 10 - RECREATION
I can read as much as I want to with moderate pain in my neck.
I can't read as much as I want to because of moderate pain in my
I am able to engage in all my recreational activities with no neck
neck.
pain.
I can hardly read at all because of severe pain in my neck.
I am able to engage in all my recreational activities with some
neck pain.
I cannot read at all.
I am able to engage in most, but not all of my usual recreational
SECTION 5 - HEADACHES
activities because of neck pain.
I am able to engage in a few of my usual recreational activities
I have no headache at all.
because of neck pain.
I have slight headaches which come infrequently.
I can hardly do any recreational activities because of neck pain.
I have moderate headaches which come infrequently.
I can't do any recreational activities at all.
I have moderate headaches which come frequently.
I have severe headaches which come frequently.
I have headaches almost all the time.
NECK PAIN SCALE
Rate the severity of your Neck Pain by indicating on the following scale.
Absence
I-----------------------------------------------------------------I
Extreme
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