Neck Pain And Disability Index (Vernon-Mior) Questionnaire Template

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NECK PAIN AND DISABILITY INDEX (Vernon-Mior)
Patient Name: _____________________________________________ File#: __________________ Date: _______________________
PLEASE READ THE INSTRUCTIONS:
This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to
manage in everyday life. Please answer every section and mark in each section only one box which applies to you. We
realize you may consider that two of the statements in any one section relate to you, but just mark the box which most
closely describes your problem.
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 moderate at the moment.
I can concentrate fully when I want to with slight difficulty.
The pain is fairly severe at the moment.
I have a fair degree of difficulty in concentrating when I
The pain is very severe at the moment.
want to.
The pain is the worst imaginable at the moment.
I have a lot of difficulty in concentrating when I want to.
I have a great deal of difficulty in concentrating when I
Section 2 – PERSONAL CARE (washing, dressing etc.)
want to.
I can look after myself normally without causing extra
I cannot concentrate at all.
pain.
Section 7 – WORK
I can look after myself normally but it causes extra pain.
I can do as much work as I want to.
It is painful to look after myself and I am slow and careful.
I can only do as my usual work, but no more.
I need some help but manage most of my personal care.
I can do most of my usual work, but no more.
I need help every day in most aspects of self care.
I cannot do my usual work.
I do not get dressed and I wash with difficulty and stay in
I can hardly do any work at all.
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 any 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
Pain prevents me from lifting heavy weights off the floor,
neck.
but I can manage if they are conveniently positioned, for
I can drive my car as long as I want with moderate pain in
example on a table.
my neck.
Pain prevents me from lifting heavy weights, but I can
I can not drive my car as long as I want because of
manage light to medium weights if they are conveniently
moderate pain in my neck.
positioned.
I can hardly drive at all because of severe pain in my
I can lift very light weights.
neck.
I cannot lift or carry anything at all.
I cannot drive my car at all.
Section 9 – SLEEPING
Section 4 – READING
I have no trouble sleeping.
I can read as much as I want to with no pain in my neck.
My sleep is slightly disturbed (less than 1 hour
I can read as much as I want to with slight pain in my
sleepless).
neck.
My sleep is mildly disturbed (1-2 hours sleepless).
I can read as much as I want to with moderate pain in my
My sleep is moderately disturbed (2-3 hours sleepless).
neck.
My sleep is greatly disturbed (3 – 5 hours sleepless).
I can not read as much as I want because of moderate
My sleep is completely disturbed (5 – 7 hours sleepless).
pain in my neck.
I can hardly read at all because of severe pain in my
Section 10 – RECREATION
neck.
I am able to engage in all my recreation activities with no
I cannot read at all.
neck pain at all.
I am able to engage in all my recreation activities with
Section 5 – HEADACHES
some pain in my neck.
I have no headaches at all.
I am able to engage in most, but not all of my usual
I have slight headaches which come infrequently.
recreation activities because of pain in my neck.
I have moderate headaches which come infrequently.
I am able to engage in few of my usual recreation
I have moderate headaches which come frequently.
activities because of pain in my neck.
I have severe headaches which come frequently.
I can hardly do any recreation activities because of pain
I have headaches almost all the time.
in my neck.
I cannot do any recreation activities at all.
PAIN SCALE:
Rate the severity of your pain by checking one box on the following scale.
NO PAIN
Excruciating Pain
1
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10

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