Neck Disability Index Questionnaire Template printable pdf download

Neck Disability Index

Office Use Only

This questionnaire has been designed to give us information as to how your neck pain has

Name ________________________________

affected your ability to manage in everyday life. Please answer every section and mark in each

Date _________________________________

section only the one box that applies to you. We realise you may consider that two or more

statements in any one section relate to you, but please just mark the box that most closely

describes your problem.

£ I cannot lift or carry anything

Section 1: Pain Intensity

Section 4: Reading

£ I have no pain at the moment

£ The pain is very mild at the moment

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

£ The pain is moderate at the moment

£ 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

£ The pain is fairly severe at the moment

£ I can’t read as much as I want because of moderate pain in my neck

£ The pain is very severe at the moment

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

£ The pain is the worst imaginable at the moment

£ I cannot read at all

Section 2: Personal Care (Washing, Dressing, etc.)

Section 5: Headaches

£ I can look after myself normally without causing extra pain

£ I have no headaches at all

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

£ I have slight headaches, which come infrequently

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

£ I have moderate headaches, which come infrequently

£ I need some help but can manage most of my personal care

£ I have moderate headaches, which come frequently

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

£ I have severe headaches, which come frequently

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

£ I have headaches almost all the time

Section 3: Lifting

Section 6: Concentration

£ I can lift heavy weights without extra pain

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

£ I can lift heavy weights but it gives extra pain

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

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

conveniently placed, for example on a table

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

£ Pain prevents me from lifting heavy weights but I can manage light to medium

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

weights if they are conveniently positioned

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

£ I can only lift very light weights

£ I cannot concentrate at all

Neck Disability Index Questionnaire Template

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