Neck Disability Index

Section 1: Pain Intensity*
Section 1: Pain Intensity (Please select the answer that most closely identifies your situation)
- I have no 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
Please describe how your pain intensity affects your daily life*
Please describe how your pain intensity affects your daily life

Section 2: Personal Care (Washing, Dressing, etc.)*
Section 2: Personal Care (Washing, Dressing, etc.) (Please select the answer that most closely identifies your situation)
- 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 self care
- I do not get dressed, I wash with difficulty and stay in bed
Please describe how your neck injury has affected your ability to address your personal care*
Please describe how your neck injury has affected your ability to address your personal care

Section 3: Lifting*
Section 3: Lifting (Please select the answer that most closely identifies your situation)
- I can lift heavy weights without extra pain
- I can lift heavy weights but it gives extra pain
- Pain prevents me 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 but I can manage light to medium weights if they are conveniently positioned
- I can only lift very light weights
- I cannot lift or carry anything
Please describe how your difficulty lifting affects your daily life*
Please describe how your difficulty lifting affects your daily life

Section 4: Reading*
Section 4: Reading (Please select the answer that most closely identifies your situation)
- I can read as much as I want to with no pain in my neck
- I can read as much as I want to with slight pain in my neck
- I can read as much as I want with moderate pain in my neck
- I can’t read as much as I want because of moderate pain in my neck
- I can hardly read at all because of severe pain in my neck
- I cannot read at all
Please describe how your difficulty reading affects your daily life*
Please describe how your difficulty reading affects your daily life

Section 5: Headaches*
Section 5: Headaches (Please select the answer that most closely identifies your situation)
- 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
Please describe how your headaches affect your daily life*
Please describe how your headaches affect your daily life

Section 6: Concentration*
Section 6: Concentration (Please select the answer that most closely identifies your situation)
- I can concentrate fully when I want to with no difficulty
- I can concentrate fully when I want to with slight difficulty
- I have a fair degree of difficulty in concentrating when I want to
- I have a lot of difficulty in concentrating when I want to
- I have a great deal of difficulty in concentrating when I want to
- I cannot concentrate at all
Please describe how your difficulty concentrating affects your daily life*
Please describe how your difficulty concentrating affects your daily life

Section 7: Work*
Section 7: Work (Please select the answer that most closely identifies your situation)
- I can do as much work as I want to
- I can only 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
Please describe how your difficulty working affects your daily life*
Please describe how your difficulty working affects your daily life

Section 8: Driving*
Section 8: Driving (Please select the answer that most closely identifies your situation)
- 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 can’t 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 can’t drive my car at all at all
Please describe how your difficulty driving affects your daily life*
Please describe how your difficulty driving affects your daily life

Section 9: Sleeping*
Section 9: Sleeping (Please select the answer that most closely identifies your situation)
- I have no trouble sleeping
- My 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)
Please describe how your difficulty sleeping affects your daily life*
Please describe how your difficulty sleeping affects your daily life

Section 10: Recreation*
Section 10: Recreation (Please select the answer that most closely identifies your situation)
- I am able to engage in all my recreation activities with no neck pain at all
- I am able to engage in all my recreation activities, with some pain in my neck
- I am able to engage in most, but not all of my usual recreation activities because of pain in my neck
- I am able to engage in a few of my usual recreation activities because of pain in my neck
- I can hardly do any recreation activities because of pain in my neck
- I can’t do any recreation activities at all
Please describe how your neck injury has affected your recreational activities*
Please describe how your neck injury has affected your recreational activities

Cervical Radiculopathy*
Cervical radiculopathy is pain that spreads into the arm, neck, chest, upper back and/or shoulders and can be associated when neck trauma occurs. Please select any of the symptoms below that you have experienced (Select all that apply)
- Muscle weakness in the fingers, hands, arms, chest, upper back and/or shoulders
- Numbness in the fingers, hands, arms, chest, upper back and/or shoulders
- Tingling in the fingers, hands, arms, chest, upper back and/or shoulders
- Pain in the fingers, hands, arms, chest, upper back and/or shoulders
- Lack of coordination in the fingers, hands and/or arms
For the areas you checked for cervical radiculopathy, please give details as to what you are experiencing*
For the areas you checked for cervical radiculopathy, please give details as to what you are experiencing

On a scale of 1 to 10 what is your current pain level due to your neck injury? (1= No pain, 10 = Most severe pain)*
On a scale of 1 to 10 what is your current pain level due to your neck injury? (1= No pain, 10 = Most severe pain)
1 2 3 4 5 6 7 8 9 10

Please list all the medication you are taking for your neck injury*
Please list all the medication you are taking for your neck injury

Please list the name of each medication. The frequency you are taking it. (e.g. 1x daily or 3x weekly etc.) and the duration. (How long have you been taking it.) Click the + sign to add additional rows.
Medication Name Frequency Duration

Medication Name	Frequency	Duration