Neck Disability Index Questionnaire - Orthobalance Physical Therapy printable pdf download

Neck Disability Index Questionnaire - Orthobalance Physical Therapy

Attilio S. Pensavalle, PT DPT

Doctor of Physical Therapy

287 Northern Boulevard, Suite 104

Great Neck, New York 11021

Tel: 1-516-482-0100 Fax: 1-516-482-0172

Neck Disability Index Questionnaire

NAME: __________________

DATE:

_______________________

Check ONE box next to each question…

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.

Personal Care (Washing, Dressing etc.)

__ I can look after myself 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 every day in most aspects of self-care.

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

Lifting

__ I can lift heavy weights without extra pain.

__ I can lift heavy weights, but it causes extra pain.

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

for example, on a table.

__ Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are

conveniently positioned.

__ I can lift very light weights.

__ I cannot lift or carry anything at all.

Reading

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

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

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

__ I cannot read as much as I want because of moderate pain in my neck.

__ I cannot read as much as I want because of severe pain in my neck.

__ I cannot read at all.

Neck Disability Index Questionnaire - Orthobalance Physical Therapy