Neck Disability Index (NDI)

Neck Disability Index form

This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.
Name*

First NameLast Name
Date

MonthDayYear
Date
Please check off the answer that best applies:
Please rate your pain level with activity:*
0= No Pain, 10 = Very Severe Pain
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 worse imaginable at the moment
Personal Care (washing, dressing, etc)*

I can look after myself normally without 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 manage most of my personal careI need help every day in most aspects of self careI cannot get dressed, wash with difficulty, and stay in bed
Lifting*

I can lift heavy weights without extra painI can lift heavy weights but it gives me extra painPain prevents me from lifting heavy weights off the floor but I can manage if they are on a tablePain prevents me from lifting heavy weights but I can manage if they are conveniently placedI can lift only very light weightsI cannot lift or carry anything at all
Headache*

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 infrequentlyI have headaches almost all the time
Recreation*

I am able to engage in all my recreational activities without painI am able to engage in my recreational activities with some painI am able to engage in most but not all of my usual recreational activities because of my neck painI am able to engage in a few of my usual recreational activities with some neck painI can hardly do any recreational activities because of neck painI can't do any recreational activities at all
Reading*

I can read as much as I want with no pain in my neckI can read as much as I want with slight neck painI can read as much as I want with moderate neck painI can't read as much as I want because of moderate neck painI can hardly read at all because of severe neck painI cannot read at all because of neck pain
Work*

I can do as much 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 usual work at allI can't do any work at all
Sleeping*

Pain does not prevent me from sleeping wellMy sleep is slightly disturbed (My sleep is mildly disturbed (1-2 hr. sleep loss)My sleep is moderately disturbed (2-3 hr. sleep loss)My sleep is greatly disturbed (3-4 hr. sleep loss)My sleep is completely disturbed (5-7 hr. sleep loss)
Concentration*

I can concentrate fully when I want with no difficultyI can concentrate fully when I want with slight difficultyI have a fair degree of difficulty concentrating when I wantI have a lot of difficulty concentrating when I wantI have great difficulty concentrating when I wantI cannot concentrate at all
Driving*

I can drive my car without neck painI 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 can't drive my car as long as I want because of moderate pain.I can hardly drive my car at all because of severe neck pain.I can't drive my car at all.
Physical Therapist:
If you don't know your physical therapist, please leave it blank.
Should be Empty:

Neck Disability Index form

Please check off the answer that best applies: