Neck Disability Index
Self-Reported Neck Disability Index Score
Name
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First Name
Last Name
Email
*
example@example.com
Today's Date
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Month
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Day
Year
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)
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Month
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Day
Year
Date
VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)
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1. How intense is your pain?
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No pain.
Mild pain.
Moderate pain
Fairly severe pain
Very severe pain
Worst imaginable pain
2. Personal care (washing, dressing, etc). How are you managing?
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I can look after myself normally without causing extra pain
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 need some help but can manage most of my personal care
I need help every day in most aspects of personal care.
I cannot get dressed, I wash with difficulty, and stay in bed most of the time.
3. Lifting
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I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example, 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 placed, for example, on a table.
I can only lift very light weights.
I cannot lift or carry anything.
4. Reading
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I can read as much as I want to with no neck pain.
I can read as much as I want to with slight neck pain.
I can read as much as I want to with moderate neck pain.
I can't read as much as I want to because of moderate neck pain.
I can hardly read at all because of severe pain in my neck.
I cannot read at all.
5. Headaches
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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 headaches almost all the time.
6. Concentration
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I can concentrate fully when I want to with no difficulty
I can concentrate fully when I want to with slight difficulty
I have fair degree of difficulty concentrating when I want.
I have a lot of difficulty concentrating when I want.
I have a great deal of difficulty concentrating when I want.
I cannot concentrate at all because of my neck pain.
7. Work
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I can do as much work as I want to.
I can do my usual work, but no more.
I can do most of my usual work, but no more.
I cannot do my usual work.
I can hardly do any work at all.
I can't do any work at all.
8. Driving
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I can drive my car without any neck pain.
I can drive my car as long as I want with slight pain in my neck.
I can drive my car as long as I want with moderate pain in my neck.
I cannot drive my car as long as I want because of moderate pain in my neck.
I can hardly drive at all because of severe pain in my neck.
I cannot drive at all.
9. Sleeping
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I have not trouble sleeping
My sleep is slightly disturbed (less than 1 hour sleepless)
My sleep is mildly disturbed (less than 1-2 hours sleepless)
My sleep is moderately disturbed (less than 2-3 hours sleepless)
My sleep is greatly disturbed (less than 3-5 hours sleepless)
My sleep is completely disturbed (less than 5-7 hours sleepless)
10. Recreation
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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 pain in my neck.
I am able to engage in most, but not all of all my usual recreational activities because of pain in my neck.
I am able to engage in a few of my usual recreational activities because of pain in my neck.
I can hardly do any recreational activities because of pain in my neck.
I can't do any recreational activities at all.
Total score out of 50
Total score in percentage
Submit
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