Neck Disability Index Questionnaire - Clinical Health Services

Neck Disability Index Questionnaire - Clinical Health Services - 2007

NECK DISABILITY INDEX QUESTIONNAIRE

Page 1 of 3

NECK DISABILITY INDEX QUESTIONNAIRE

Name:____________________

Ref. Dr:___________________

Date: _______

ID#: _______________

Age: _______

Gender: M / F

Please read:

This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to

manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to

you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CIRCLE

THE ONE CHOICE, WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

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.)

I can look after myself normally without causing extra pain.

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

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

e.g., on 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.

8/2/2007

Neck Disability Index Questionnaire - Clinical Health Services - 2007