Neck Disability Index Questionnaire Form
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1Name:
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D ate:
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Age:
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Gender:
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Initial
Final
NECK DISABILITY INDEX QUESTIONNAIRE
This questionnaire is designed to help us better understand how your neck pain affects your ability to
manage everyday life activities. Please mark in each section the ONE BOX that applies to you.
Although you may consider that 2 of the statements in any one section relate to you, please mark the
box that MOST CLOSELY describes your present-day situation.
S
1 - P
I
S
6 - C
ECTION
AIN
NTENSITY
ECTION
ONCENTRATION
☐ I have no pain at the moment.
☐ I can concentrate fully without difficulty.
☐ The pain is mild at the moment.
☐ I can concentrate fully with slight difficulty.
☐ The pain is moderate at the moment
☐ I have a fair degree of difficulty concentrating.
☐ The pain is fairly severe at the moment.
☐ I have a lot of difficulty concentrating.
☐ The pain is very severe at the moment.
☐ I have a great deal of difficulty concentrating.
☐ The pain is the worst imaginable at the moment.
☐ I cannot concentrate at all.
S
2 - P
C
S
7 - S
ECTION
ERSONAL
ARE
ECTION
LEEPING
☐
☐ I have no trouble sleeping.
I can look after myself without causing extra pain.
☐
I can look after myself normally but it causes extra pain.
☐ My sleep is slightly disturbed for less than 1 hour.
☐
It is painful to look after myself and I am slow and careful.
☐ My sleep is mildly disturbed for up to 1-2 hours.
☐
I need some help, but manage most of my personal care.
☐ My sleep is moderately disturbed for up to 2-3 hours.
☐
I need help every day in most aspects of self-care.
☐ My sleep is greatly disturbed for up to 3-5 hours.
☐
☐ My sleep is completely disturbed for up to 5-7 hours.
I do not get dressed. I wash with difficulty and stay in bed.
S
3 - L
S
8 - D
ECTION
IFTING
ECTION
RIVING
☐ I can lift heavy weights without extra pain.
☐ I can drive my car without neck pain.
☐ I can lift heavy weights, but it causes extra pain.
☐ I can drive as long as I want with slight neck pain.
☐ Pain prevents me from lifting heavy weights off the floor
☐ I can drive as long as I want with moderate neck pain.
☐ I can’t drive as long as I want because of moderate
but I can manage if items are conveniently positioned (i.e.,
on a table).
neck pain.
☐ Pain prevents me from lifting heavy weights, but I can
☐ I can hardly drive at all because of severe neck pain
manage light to medium weights if they are conveniently
☐ I cannot drive my car at all because of neck pain.
positioned.
☐ I can lift only very light weights.
S
9 - R
ECTION
EADING
☐ I cannot lift or carry anything at all.
☐ I can read as much as I want to with no neck pain.
☐ I can read as much as I want with slight neck pain.
S
4 - W
☐ I can read as much as I want with moderate neck pain.
ECTION
ORK
☐ I can do as much work as I want to.
☐ I can’t read as much as I want because of moderate
☐ I can only do my usual work, but no more.
neck pain.
☐ I can do most of my usual work, but no more.
☐ I can’t read as much as I want because of severe neck
☐ I cannot do my usual work.
pain.
☐ I can hardly do any work at all.
☐ I cannot read at all.
☐ I cannot do any work at all.
S
10 - R
ECTION
ECREATION
S
☐ I have no neck pain during all recreational activities.
5 - H
ECTION
EADACHES
☐ I have no headaches at all.
☐ I have some neck pain with all recreational activities.
☐ I have slight headaches that come infrequently.
☐ I have some neck pain with a few recreational
☐ I have moderate headaches that come in-frequently.
activities.
☐ I have moderate headaches that come frequently.
☐ I have neck pain with most recreational activities.
☐ I have severe headaches that come frequently.
☐ I can hardly do recreational activities due to neck pain.
☐ I have headaches almost all the time.
☐ I can’t do any recreational activities due to neck pain.
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