telmagrant

Neck Disability Index
Name
DOB

YearMonthDay
Date
Today's Date

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Date
Section 1: Pain Intensity

I have no pain at the momentThe pain is very mild at the momentThe pain is moderate at the momentThe pain is fairly severe at the momentThe pain is very severe at the momentThe pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)

I can look after myself normally without causing extra painI can look after myself normally but it causes extra painIt is painful to look after myself and I am slow and carefulI need some help but can manage most of my personal careI need help every day in most aspects of self careI do not get dressed, I wash with difficulty and stay in bed
Section 3: Lifting

I can lift heavy weights without extra painI can lift heavy weights but it gives extra painPain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a tablePain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positionedI can only lift very light weightsI cannot lift or carry anything
Section 4: Reading

I can read as much as I want to with no pain in my neckI can read as much as I want to with slight pain in my neckI can read as much as I want with moderate pain in my neckI can’t read as much as I want because of moderate pain in my neckI can hardly read at all because of severe pain in my neckI cannot read at all
Section 5: Headaches

I have no headaches at allI have slight headaches, which come infrequentlyI have moderate headaches, which come infrequentlyI have moderate headaches, which come frequentlyI have severe headaches, which come frequentlyI have headaches almost all the time
Section 6: Concentration

I can concentrate fully when I want to with no difficultyI can concentrate fully when I want to with slight difficultyI have a fair degree of difficulty in concentrating when I want toI have a lot of difficulty in concentrating when I want toI have a great deal of difficulty in concentrating when I want toI cannot concentrate at all
Today's Date

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Section 7: Work

I can do as much work as I want toI can only do my usual work, but no moreI can do most of my usual work, but no moreI cannot do my usual workI can hardly do any work at allI can’t do any work at all
Section 8: Driving

I can drive my car without any neck painI can drive my car as long as I want with slight pain in my neckI can drive my car as long as I want with moderate pain in my neckI can’t drive my car as long as I want because of moderate pain in my neckI can hardly drive at all because of severe pain in my neckI can’t drive my car at all
Section 9: Sleeping

I have no trouble sleepingMy sleep is slightly disturbed (less than 1 hr sleepless)My sleep is mildly disturbed (1-2 hrs sleepless)My sleep is moderately disturbed (2-3 hrs sleepless)My sleep is greatly disturbed (3-5 hrs sleepless)My sleep is completely disturbed (5-7 hrs sleepless)
Section 10: Recreation

I am able to engage in all my recreation activities with no neck pain at allI am able to engage in all my recreation activities, with some pain in my neckI am able to engage in most, but not all of my usual recreation activities because of pain in my neckI am able to engage in a few of my usual recreation activities because of pain in my neckI can hardly do any recreation activities because of pain in my neckI can’t do any recreation activities at all
Score: ____/50
Scoring: Add up the value (0 to 5) of each question. Maximum score is 50. Enter score into PPS under NDI Score on Higher=Worse, Lower=Better.

Increase=Worsening, Decrease=Improvement
Numerical Pain Rating Scale (NPRS): With respect to your pain, over the last 24 hours, how bad has your pain been? Select the appropriatenumber.

No Pain 0Mild 1 -3Moderate 4Severe 5-6Very Severe 7-9Worst Pain Possible 10
Patient Name
Date of Birth

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Date
Today's Date

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Neck Disability Index