Dr Boswell Neck Disability Index Questionnaire printable pdf download

NECK DISABILITY INDEX QUESTIONNAIRE

Complete the questionnaire below as to how your neck pain has affected your ability to manage in everyday life. Please

mark just ONE response in each section which most clearly describes your problem.

SURGERY: If you have had surgery, are you pleased with the results, and would you recoomend the procedure to others?

(if applicable) Yes: ____ No: ____

SECTION 1: PAIN INTENSITY

SECTION 7 WORK

___ I have no pain at the moment

___I can do as much work as I want

___ The pain is very mild at the moment

___I can do my usual work, but no more

___ The pain is moderate at the moment

___I can do most of my usual work, but no more

___ The pain is fairly severe at the moment

___I cannot do my usual work

___ The pain is very severe at the moment

___I can hardly do any work at all

___ The pain is the worse imaginable at the moment

___I cannot do any work at all

SECTION 2: Personal Care (washing, dressing)

SECTION 8 DRIVING

___ I can look after myself normally without causing extra

___I can drive my car without neck pain

pain

___I can drive my car as long as I want with

___ I can look after myself normally but it causes extra

slight pain in the neck

pain

___I can drive my car as long as I want with

___ It is painful to look after myself, I am slow and careful

moderate pain in my neck

___ I need some help but manage most my personal care

___I cannot drive my car as long as I want

___ I need help every day in most aspects of self−care

because of moderate pain in my neck

___ I do not get dressed, I wash with difficulty & stay in bed

___I can hardly drive at all because of severe

pain in my neck

___I cannot drive my car at all

SECTION 3 LIFTING

___I can lift heavy weights without extra pain

___I can lift heavy weights but it gives extra pain

SECTION 9 SLEEPING

___Pain prevents me from lifting heavy weights off the

___I have no trouble sleeping

floor, but can manage if conveniently positioned

___My sleep is slightly disturbed (<1hr)

___Pain prevents me from lifting heavy weights, but I can

___My sleep is mildly disturbed (1−2hrs)

manage light to medium weights if they are

___My sleep is moderately disturbed (2−3 hrs

conveniently postioned

sleepless)

___I can lift very light weights

___My sleep is greatly disturbed (3−5 hrs)

___I cannot lift or carry anything at all

___My sleep is completely disturbed (5−7 hrs

sleepness)

SECTION 4 READING

___I can read as much as I want with no neck pain

___I can read as much as I want with slight neck pain

SECTION 10 RECREATION

___I can read as much as I want with slight neck pain

___I am able to engage in all my recreation

___I cannot read as much as I want because of moderate

activities with no neck pain

neck pain

___I am able to engage in all my recreation

___I can hardly read at all because of severe neck pain

activities; some neck pain

___I cannot read at all

___I am able to engage in most, but not all of my

usual recreation activities because of neck

pain

SECTION 5 HEADACHES

___I am able to engage in a few of my usual

___I have no headaches at all

recreation activities because of neck pain

___I have slight headaches that come infrequently

___I can hardly do any recreation activities

___I have moderate headaches which come infrequently

because of neck pain

___I have severe headaches which come frequently

___I cannot do any recreation activities at all

___I have headaches almost all the time

SECTION 6 CONCENTRATION

___I can concentrate fully when I want 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 concentrating when I

want to

___I cannot concentrate at all

neuroneck 6/2/15

Dr Boswell Neck Disability Index Questionnaire

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