Neck Pain Disability Index Questionnaire printable pdf download

NECK PAIN DISABILITY INDEX QUESTIONNAIRE

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

SECTION 6 - Concentration

A I have no pain at the moment.

A I can concentrate fully when I want to with no difficulty.

B The pain is very mild at the moment.

B I can concentrate fully when I want to with slight difficulty.

C The pain is moderate at the moment.

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

D The pain is fairly severe at the moment.

D I have a lot of difficulty in concentrating when I want to.

E The pain is very severe at the moment.

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

F The pain is the worst imaginable at the moment.

F I cannot concentrate at all.

SECTION 2 -Personal Care (Washing, Dressing, etc.)

SECTION 7 - Work

A I can look after myself normally without causing extra pain.

A I can do as much work as I want to.

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

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

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

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

D I need some help, but manage most of my personal care.

D I cannot do my usual work.

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

E I can hardly do any work at all.

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

F I cannot do any work at all.

SECTION 3 - Lifting

SECTION 8 - Driving

A I can lift heavy weights without extra pain.

A I can drive my car without any neck pain.

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

B I can drive my car as long as I want with slight pain in my neck.

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

C I can drive my car as long as I want with moderate pain in my

can manage if they are conveniently positioned, for example, on a

neck.

table.

D I cannot drive my car as long as I want because of moderate pain in

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

my neck.

light to medium weights if they are conveniently positioned.

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

E I can lift very light weights.

F I cannot drive my car at all.

F I cannot lift or carry anything at all.

SECTION 4 - Reading

SECTION 9 - Sleeping

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

A I have no trouble sleeping.

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

B My sleep is slightly disturbed (less than 1 hour sleepless).

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

C My sleep is mildly disturbed (1-2 hours sleepless).

D I cannot read as much as I want because of moderate pain in my

D My sleep is moderately disturbed (2-3 hours sleepless).

neck.

E My sleep is greatly disturbed (3-5 hours sleepless).

E I cannot read as much as I want because of severe pain in my

F My sleep is completely disturbed (5-7 hours)

neck.

F I cannot read at all.

SECTION 5 - Headaches

SECTION 10 - Recreation

A I am able to engage in all of my recreational activities with no neck

A I have no headaches at all.

pain at all.

B I have slight headaches which come infrequently.

B I am able to engage in all of my recreational activities with some

C I have moderate headaches which come infrequently.

pain in my neck.

D I have moderate headaches which come frequently.

C I am able to engage in most, but not all of my recreational activities

E I have severe headaches which come frequently.

because of pain in my neck.

F I have headaches almost all the time.

D I am able to engage in a few of my recreational activities because of

pain in my neck.

E I can hardly do any recreational activities because of pain in my

neck.

F I cannot do any recreational activities at all.

COMMENTS:

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NAME: ______________________________________ DATE: ____________ SCORE: ________________

Neck Pain Disability Index Questionnaire

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