Neck Disability Index Questionnaire Template printable pdf download

Neck Disability Index

Name

Date

Therapist_______________

This questionnaire has been designed to give your therapist information as to how your neck pain has affected you in

your everyday life activities. Please answer each section; marking only the ONE box which best describes your status

today.

Section 1— 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 worst imaginable at the moment.

Section 2— Personal Care (Washing, dressing, etc.)

1 can look after myself normally without causing extra pain.

I can look after myself normally but it causes me 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 do not get dressed, wash with difficulty and stay in bed.

Section 3—Lifting

I can lift heavy weights without extra pain.

I can lift heavy weights but it causes extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently

positioned, for example on a table.

Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are

conveniently positioned.

I can lift only very light weights.

I cannot lift or carry anything at all.

Section 4— Reading

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

I can read as much as I want to with slight pain in my neck.

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

I can't read as much as I want because of moderate pain in my neck.

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

I cannot read at all.

Section 5— Headache

I have no headache at all.

I have slight headaches that come infrequently.

I have moderate headaches that come infrequently.

I have moderate headaches that come frequently.

I have severe headaches that come frequently.

I have headaches almost all the time.

Neck Disability Index Questionnaire Template