Complete Chiropractic – Neck pain disability index

Neck pain disability index

This neck pain disability index form should be used if you have been directed to do so by your doctor.

Part 1

About you

Your Prefix *

Your First Name *

Your Last Name *

Email Address *

Section 2

Your neck pain

This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by selecting the one choice that most applies to you.

We realise that you may feel that more than one statement may relate to you, but please choose just the one which fits best.

How does your neck pain impact you?

Pain intensity *I have no neck pain at the moment.The pain is very mild at the moment.The pain is moderate at the moment.The pain is fairly severe at the moment.The pain is very severe at the moment.The pain is the worst imaginable at the moment.

Personal Care *I can look after myself normally without causing extra neck pain.I can look after myself normally, but it causes extra neck painIt is painful to look after myself, and I am slow and careful I need some help but manage most of my personal care. I need help every day in most aspects of self -care.I do not get dressed. I wash with difficulty and stay in bed.

Lifting *I can lift heavy weights without causing extra neck pain.I can lift heavy weights, but it gives me extra neck pain.Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.Neck pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positionedI can lift only very light weights.I cannot lift or carry anything at all.

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.I can read as much as I want with moderate neck pain.I can't read as much as I want because of moderate neck pain.I can't read as much as I want because of severe neck pain.I can't read at all.

Headaches *I have no headaches at all.have slight headaches that come infrequently.I have moderate headaches that come infrequentlyI have moderate headaches that come frequently. I have severe headaches that come frequently.I have headaches almost all the time

Concentration *I can concentrate fully without difficultyI can concentrate fully with slight difficulty.I have a fair degree of difficulty concentrating.I have a lot of difficulty concentrating.I have a great deal of difficulty concentrating.I can't concentrate at all.

Work *I can do as much work as I want.I can only do my usual work, but no more.I can do most of my usual work, but no more.I can't do my usual work.I can hardly do any work at all.I can't do any work at all.

Driving *I can drive my car without neck pain.I can drive my car with only slight neck pain.I can drive as long as I want with moderate neck pain.I can't drive as long as I want because of moderate neck pain.I can hardly drive at all because of severe neck pain.I can't drive my care at all because of neck pain.

Sleeping *I have no trouble sleeping.My sleep is slightly disturbed for less than 1 hour.My sleep is mildly disturbed for up to 1-2 hours.My sleep is moderately disturbed for up to 2-3 hoursMy sleep is greatly disturbed for up to 3-5 hours.My sleep is completely disturbed for up to 5-7 hours.

Recreation *I am able to engage in all my recreational activities with no neck pain at all.I am able to engage in all my recreational activities with some neck pain.I am able to engage in most, but not all of my recreational activities because of pain in my neck.I am able to engage in a few of my recreational activities because of neck pain.I can hardly do recreational activities due to neck pain.I can't do any recreational activities due to neck pain.

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