Wake Forest

Cary

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Wake Forest | 919.556.4678

Cary | 919.468.0955

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Neck Disability Index

Patient First Name*
Patient Last Name*
Date Of Birth*
MM slash DD slash YYYY
This questionnaire has been designed to give your therapist information as to how your neck pain has affected your ability to manage in every day life. Please answer every question. For each question, place a check mark by the statement that BEST describes your condition today. We realize you may feel that two of the statements may describe your condition, but please mark only the line which most closely describes your current condition.
Pain Intensity*
- I have no pain at the moment.
- The pain is very mild at the moment.
- The pain comes and goes and is moderate.
- The pain is fairly severe at the moment.
- The pain is very severe at the moment.
Sleeping*
- I have no trouble sleeping.
- I have no trouble sleeping.
- My sleep is mildly disturbed (1-2 hours sleepless).
- My sleep is moderately disturbed (2-3 hours sleepless).
- My sleep is greatly disturbed (3-5 hours sleepless).
- My sleep is completely disturbed (5-7 hours sleepless).
Reading*
- Reading
- 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 cannot read as much as I want because of moderate neck pain.
- I can hardly read at all because of severe neck pain.
- I cannot read at all because of neck pain.
Concentration*
- I can concentrate fully when I want with no difficulty.
- I can concentrate fully when I want with slight difficulty.
- I have a fair degree of difficulty concentrating when I want.
- I have a great deal of difficulty concentrating when I want.
- I cannot 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 only do most of my usual work but no more.
- I cannot do my usual work.
- I cannot do any work at all.
Personal Care*
- Personal Care
- I can look after myself normally but it causes extra pain.
- It is painful to look after myself and I am slow and careful.
- I do not get dressed, I wash with difficulty and stay in bed.
- I need help every day in most aspects of self care.
Lifting*
- I can lift heavy weights without extra pain.
- I can only lift very light weights.
- Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table).
- Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.
- I cannot lift or carry anything at all.
Driving*
- I can drive my car without any neck pain.
- I can drive my car as long as I want with slight neck pain.
- I can drive my car as long as I want with moderate neck pain.
- I cannot drive my car at all because of neck pain.
- I cannot drive my car as long as I want because of moderate neck pain.
- I can hardly drive at all because of severe neck pain.
Recreation*
- I am able to engage in all my recreation activities without neck pain.
- I am able to engage in most but not all my usual recreation activities because of neck pain.
- I am only able to engage in a few of my usual recreation activities because of neck pain.
- I can hardly do any recreation activities because of neck pain.
- I cannot do any recreation activities at all.
Headaches*
- I have no headaches at all.
- I have slight headaches which come infrequently.
- I have moderate headaches which come infrequently.
- I have moderate headaches which come frequently.
- I have severe headaches which come frequently.
- I have severe headaches which come frequently.
Today's Date: 03/29/2023
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10560 Ligon Mill Road #109 | Wake Forest, NC 27587
1021 Darrington Drive #205 | Cary, NC 27513
919.556.4678

Voted one of the best Wake Forest Physical Therapy Clinics multiple years in a row. Locally owned & operated.

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