Neck Disability Index Questionnaire, Revised Oswestry Back Pain Disability Index
ADVERTISEMENT
1
2PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage
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 one choice that most closely describes your condition right now. Answer the last
statement by circling the choice that most accurately describes your condition before your symptoms started.
Neck Disability Index Questionnaire
SECTION 1- Pain Intensity
SECTION 6- Concentration
q
q
A I have no pain at the moment.
A I can concentrate fully when I want to with no difficulty.
q
q
B The pain is very mild at the moment.
B I can concentrate fully when I want to with slight difficulty.
q
q
C The pain comes and goes and is moderate.
C I have a fair degree of difficulty in concentrating when I want to.
q
q
D The pain is moderate and does not vary much.
D I have a lot of difficulty in concentrating when I want to.
q
q
E The pain is severe but comes and goes.
E I have a great deal of difficulty in concentrating when I want to.
q
q
F The pain is severe and does not vary much.
F I cannot concentrate at all.
q
q
q
q
q
q
q
q
q
q
q
q
Before my current symptom started, I was an
A
B
C
D
E
F
Before my current symptoms started, I was an
A
B
C
D
E
F
SECTION 2 -Personal Care (Washing, Dressing, etc)
SECTION 7- Work
q
q
A I can look after myself normally without causing extra pain.
A I can do as much work as I want to.
q
q
B I can look after myself normally, but it causes extra pain.
B I can only do my usual work, but no more.
q
q
C It is painful to look after myself and lam slow and careful
C I can do most of my usual work, but no more.
q
q
D I need some help, but manage most of my personal care.
D I cannot do my usual work.
q
q
E I need help every day in most aspects of self care.
E I can hardly do any work at all.
q
q
F I do not get dressed, I wash with difficulty and stay in bed.
F I cannot do any work at all.
q
q
q
q
q
q
q
q
q
q
q
q
Before my current symptoms started, I was an
A
B
C
D
E
F
Before my current symptoms started, I was an
A
B
C
D
E
F
SECTION 3- Lifting
SECTION 8- Driving
q
q
A I can lift heavy weights without extra pain.
A I can drive my car without any neck pain.
q
q
B I can lift heavy weights, but it causes extra pain.
B I can drive my car as long as I want with slight pain in my neck.
q
q
C Pain prevents me from lifting heavy weights off the floor, but I can if
C I can drive my car as long as I want with moderate pain in my neck.
q
they are conveniently positioned, for example, on a table.
D I cannot drive my car as long as I want because of moderate pain in
q
D Pain prevents me from lifting heavy weights, but I can manage light
my neck.
q
to medium weights if they are conveniently positioned.
E I can hardly drive at all because of severe pain in my neck.
q
q
E I can lift very light weights.
F I cannot drive my car at all.
q
F I cannot lift or carry anything at all.
q
q
q
q
q
q
q
q
q
q
q
q
Before my current symptoms started, I was an
A
B
C
D
E
F
Before my current symptoms started, I was an
A
B
C
D
E
F
SECTION 4-Reading
SECTION 9-Sleeping
q
q
A I can read as much as I want to with no pain in my neck.
A I have no trouble sleeping.
q
q
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).
q
q
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).
q
q
D I cannot read as much as I want because of moderate pain in my neck.
D My sleep is moderately disturbed (2-3 hours sleepless).
q
q
E I cannot read as much as I want because of severe pain in my neck.
E My sleep is greatly disturbed (3-5 hours sleepless).
q
q
F I cannot read at all.
F My sleep is completely disturbed (5-7 hours sleepless).
.
q
q
q
q
q
q
q
q
q
q
q
q
Before my current symptoms started, I was an
A
B
C
D
E
F
Before my current symptoms started, I was an
A
B
C
D
E
F
SECTION 5 - Headaches
SECTION 10- Recreation
q
q
A I have no headaches at all.
A I am able to engage in all of my recreational activities with no neck
q
pain at all.
B I have slight headaches which come infrequently.
q
q
B I am able to engage in all of my recreational activities with some pain
C I have moderate headaches which come infrequently,
in my neck.
q
D I have moderate headaches which come frequently.
q
C I am able to engage in most, but not all of my recreational activities
q
E I have severe headaches which come frequently.
because of pain in my neck.
q
F I have headaches almost all the time
q
D I am able to engage in a few of my recreational activities because of
pain in my neck.
q
E I can hardly do any recreational activities because of pain in my neck.
q
F I cannot do any recreational activities at all.
q
q
q
q
q
q
q
q
q
q
q
q
Before my current symptoms started, I was an
A
B
C
D
E
F
Before my current symptoms started, I was an
A
B
C
D
E
Total score: ______ x 2 = __________%
Patient Signature: _____________________________________________________
Date:________________________
Doctor Signature: _____________________________________________________
Date:________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal