Neck Disability Index Questionnaire printable pdf download

NECK DISABILITY INDEX QUESTIONNAIRE

Patient’ s Name: _________________________________________________

Today’ s Date: ______/______/______

Instructions: This questionnaire has been designed to give your doctor information as to how your neck pain has affected your ability to

manage everyday life. Please answer every section and mark in each section the ONE answer, which applies to you. We realize you may

consider that two of the statements in any one section relate to you; but please mark the answer, which most closely describes your problem.

Pain Intensity

Concentration



I have no pain at the moment.



I can concentrate fully when I want with no difficulty.



The pain is very mild at the moment.

I can concentrate fully when I want with slight difficulty.



The pain is moderate at the moment.

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



The pain is fairly severe at the moment.

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



The pain is very severe at the moment.

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



The pain is the worst imaginable at the moment.



I cannot concentrate at all.

Lifting

Work



I can lift heavy weights without extra pain.

I can do as much work as I want.



I can lift heavy weights, but it gives me extra pain.

I can only do my usual work, but no more.



Pain prevents me from lifting heavy weights off the floor, but I

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



can manage if they are conveniently positioned for example on a

I cannot do my usual work.



table.

I can hardly do any work at all.



Pain prevents me from lifting heavy weights, but I can manage

I can’ t hardly do any work at all.

light to medium weights if they are conveniently positioned.

Sleeping



I can lift very light weights.



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 hr’ s. sleepless).

Headaches



I have no headaches at all.



My sleep is moderately disturbed (2 –3 hr’ s. sleepless).



I have slight headaches, which come infrequently.

My sleep is greatly disturbed (3 –5 hr’ s. sleepless).



I have moderate headaches, which come infrequently.

My sleep is completely disturbed (5 –7 hr’ s. sleepless).



I have moderate headaches, which come frequently.

Driving



I have severe headaches, which come frequently.



I can drive my car without any neck pain.



I have headaches almost all the time.



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

Personal Care (Washing, Dressing, etc.)



I can look after myself normally without causing extra pain.

neck.



I can look after myself normally, but it causes extra pain.



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



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

in my neck.



I need help every day in most aspects of self-care.



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



I need some help every day in most aspects of self-care.



I can’ t drive my car at all.



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

Recreation



Reading

I am able to engage in all my recreation activities with no neck



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

pain at all.



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

I am able to engage in all my recreation activities with some



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

pain in my neck.



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

I am able to engage in most, but not all of my usual recreation

neck.

activities because of pain in my neck.



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

I am able to engage in a few of my usual recreation activities



I cannot read at all.

because of pain in my neck.



I can hardly do any recreation activities because of pain in my

neck.



I can’ t do any recreation activities at all.

Patient’ s Signature:__________________________________________________

NDI_Form

Version 1.0

Neck Disability Index Questionnaire

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