Neck Disability Index Questionnaire Template (Page 2 of 2) in pdf

Section 6--- Concentration

I can concentrate fully when I want to with no difficulty.

I can concentrate fully when I want to with slight difficulty.

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

I have a lot of difficulty in concentrating when I want to.

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

I cannot concentrate at all.

Section 7--- Work

I can do as much as I want to.

I can only do my usual work but no more.

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

I cannot do my usual work

I can hardly do any work at all.

I can’t do any work at all.

Section 8- Driving

I can drive my car without any neck pain.

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

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

I can’t drive my car as long as I want because of moderate pain in my neck.

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

I can’t drive my car at all.

Section 9

Sleeping

—

I have no trouble sleeping.

My sleep is slightly disturbed (less than 1 hour sleep loss)

My sleep is mildly disturbed (1-2 hour sleep loss).

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

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

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

Section 10— Recreation

I am able to engage in all my recreational activities with no neck pain at all.

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

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

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

I can hardly do any recreational activities because of pain in my neck.

I can’t do any recreational activities at all.

Comments:

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TOTAL SCORE = _________

Adapted from Vernon H, Mior S. The Neck Disability Index.: A Study of Reliability

Validity. Journal of

and

Manipulative and Physiological Therapeutics 1991; 14(7):409-415.

Neck Disability Index Questionnaire Template Page 2

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