Neck Disability Index Questionnaire - Orthobalance Physical Therapy (Page 2 of 2) in pdf

Headache

__ I have no headaches at all.

__ I have slight headaches which come infrequently.

__ I have moderate headaches which come in-frequently.

__ I have moderate headaches which come frequently.

__ I have severe headaches which come frequently.

__ I have headaches almost all the time.

Concentration

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

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

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

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

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

__ I cannot concentrate at all.

Work

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

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

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

__ I cannot do my usual work.

__ I can hardly do any work at all.

__ I cannot do any work at all.

Driving

__ I can drive my car without neck pain.

__ 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 neck.

__ I cannot drive my car as long as I want because of moderate pain in my neck.

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

__ I cannot drive my car at all.

Sleeping

__ I have no trouble sleeping

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

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

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

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

__ My sleep is completely disturbed (5-7 hours sleepless).

Recreation

__ I am able engage in all recreational activities with no pain in my neck at all.

__ I am able engage in all recreational activities with some pain in my neck.

__ I am able engage in most, but not all recreational activities because of pain in my neck.

__ I am able 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.

Neck Disability Index Questionnaire - Orthobalance Physical Therapy Page 2