Neck Disability Index Questionnaire Template
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Patient Name:__________________________________ Date of Birth:______/______/_______ Date:______/______/_______
This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please
answer by checking one box in each section for the statement that best applies to you. We realize you may consider that two or more statements
in any one section apply, but please just mark the box that indicates the statement that most clearly describes your problem at this time.
SECTION 1 - PAIN INTENSITY
SECTION 6 - CONCENTRATION
❏ I have no pain at the moment.
❏ I can concentrate fully when I want to with no difficulty.
❏ The pain is mild at the moment.
❏ I can concentrate fully when I want to with slight difficulty.
❏ The pain comes and goes and is moderate.
❏ I have a fair degree of difficulty in concentrating when I want to.
❏ The pain is moderate and does not vary much.
❏ I have a lot of difficulty in concentrating when I want to.
❏ The pain is severe but comes and goes.
❏ I have a great deal of difficulty in concentrating when I want to.
❏ The pain is severe and does not vary much.
❏ I cannot concentrate at all.
SECTION 2 - PERSONAL CARE (washing, dressing, etc.)
SECTION 7 - WORK
❏ I can look after myself without causing extra pain.
❏ I can do as much work as I want to.
❏ I can look after myself normally but it causes extra pain.
❏ I can only do my usual work, but no more.
❏ It is painful to look after myself and I am slow and careful.
❏ I can do most of my usual work, but no more.
❏ I need some help, but can manage most of my personal care.
❏ I cannot do my usual work.
❏ I need help every day in most aspects of self-care.
❏ I can hardly do any work at all.
❏ I do not get dressed, I wash with difficulty, and stay in bed.
❏ I cannot do any work at all.
SECTION 3 - LIFTING
SECTION 8 - DRIVING
❏ I can lift heavy weights without extra pain.
❏ I can drive my car without neck pain.
❏ I can lift heavy weights, but it gives me extra pain.
❏ I can drive my car as long as I want with slight pain in my neck.
❏ Pain prevents me from lifting heavy weights off the floor but I
❏ I can drive my car as long as I want with moderate pain
can manage if they are conveniently placed (e.g. on a table).
in my neck.
❏ Pain prevents me from lifting heavy weights, but I can manage
❏ I cannot drive my car as long as I want because of moderate pain
light to medium weights if they are conveniently placed.
in my neck.
❏ I can only lift very light weights.
❏ I can hardly drive my car at all because of severe pain
❏ I cannot lift or carry anything at all.
in my neck.
❏ I cannot drive my car at all.
SECTION 4 - READING
❏ I can read as much as I want to with no pain in my neck.
SECTION 9 - SLEEPING
❏ I can read as much as I want to with slight pain in my neck.
❏ I have no trouble sleeping.
❏ I can read as much as I want to with moderate pain in my neck.
❏ My sleep is slightly disturbed (less than 1 hr sleepless).
❏ I cannot read as much as I want because of moderate pain
❏ My sleep is mildly disturbed (1-2 hrs sleepless).
in my neck.
❏ My sleep is moderately disturbed (2-3 hrs sleepless).
❏ I cannot read as much as I want because of severe pain
❏ My sleep is greatly disturbed (3-5 hrs sleepless).
in my neck.
❏ My sleep is completely disturbed (5-7 hrs sleepless).
❏ I cannot read at all.
SECTION 10 - RECREATION
SECTION 5 - HEADACHES
❏ I am able to engage in all recreational activities with no
❏ I have no headaches at all.
pain in my neck at all.
❏ I have slight headaches, which come infrequently.
❏ I am able to engage in all recreational activities with some
❏ I have moderate headaches, which come infrequently.
pain in my neck.
❏ I have moderate headaches, which come frequently.
❏ I am able to engage in most, but not all, recreational activities
❏ I have severe headaches, which come frequently.
because of pain in my neck.
❏ I have headaches almost all the time.
❏ 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 cannot do any recreational activities at all.
Updated 06/10
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