Neck Disability Index

Home
Physical Therapy
Sports Performance
- Golf
- Running
- Throwing
- Hitting
Group Fitness
- Class Schedule
- Runner's Group
INFO
- Location
- News
- Blog
Golf Simulator

Please circle the answers below that BEST apply

* Indicates required field

Patient ID# *

Please rate your pain level with activity: (0= no pain; 10 = very severe pain *

0 1 2 3 4 5 6 7 8 9 10

How satisfied are you with the level of care and service provided? *

Very Satisfied Satisfied Unsatisfied Very Unsatisfied

Please rate your progress with functional activities from start of therapy to the point in time. *

Excellent Good Fair Poor

At this point in your treatment, have your therapy goals been met? *

Completely Met Mostly Met Partially Met Not Met

1. PAIN INTENSITY *

0 - I have no pain at the moment 1 - The pain is very mild at the moment 2 - The pain is moderate at the moment 3 - The pain is fairly severe at the moment 4 - The pain is very severe at the moment 5 - The pain is the worse imaginable at the moment

PERSONAL CARE (washing, dressing, etc) *

0 - I can look after myself normally without extra pain 1 - I can look after myself normally, but it causes extra pain 2 - It is painful to take care of myself, and I am slow and careful 3 - I need help, but I am able to manage most of my personal care 4 - I need help every day in most aspects of self care 5 - I cannot get dressed, wash with difficulty, and stay in bed

LIFTING *

0 - I can lift heavy weights without extra pain 1 - I can lift heavy weights, but it gives me extra pain 2 - Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are on a table 3 - Pain prevents me from lifting heavy weights, but I can manage if they are conveniently placed 4 - I can lift only very light weights 5 - I cannot lift or carry anything at all

HEADACHE *

0 - I have no headaches at all 1 - I have slight headaches which come infrequently 2 - I have moderate headaches which come infrequently 3 - I have moderate headaches which come frequently 4 - I have severe headaches which come infrequently 5 - I have headaches almost all the time

RECREATION *

0 - I am able to engage in all my recreational activities without pain 1 - I am able to engage in my recreational activities with some pain 2 - I am able to engage in most but not all of my usual recreational activities because of my neck pain 3 - I am able to engage in a few of my usual recreational activities with some neck pain 4 - I can hardly do any recreational activities because of neck pain 5 - I can't do any recreational activities at all

READING *

0 - I can read as much as I want with no pain in my neck 1 - I can read as much as I want with slight neck pain 2 - I can read as much as I want with moderate neck pain 3 - I can't read as much as I want because of moderate neck pain 4 - I can hardly read at all because of severe neck pain 5 - I cannot read at all because of neck pain

WORK *

0 - I can do as much as I want to 1 - I can only do my usual work but no more 2 - I can do most of my usual work but no more 3 - I cannot do my usual work 4 - I can hardly do any usual work at all 5 - I can't do any work at all

SLEEPING *

0 - Pain does not prevent me from sleeping well 1 - My sleep is slightly disturbed (< 1 hr sleep loss) 2 - My sleep is mildly disturbed (1-2 hr sleep loss) 3 - My sleep is moderately disturbed (2-3 hr sleep loss) 4 - My sleep is greatly disturbed (3-4 hr sleep loss) 5 - My sleep is completely disturbed (5-7 hr sleep loss)

CONCENTRATION *

0 - I can concentrate fully when I want with no difficulty 1 - I can concentrate fully when I want with slight difficulty 2 - I have a fair degree of difficulty concentrating when I want 3 - I have a lot of difficulty concentrating when I want 4 - I have great difficulty concentrating when I want 5 - I cannot concentrate at all

DRIVING *

0 - I can drive my car without neck pain 1 - I can drive my car as long as I want with slight neck pain 2 - I can drive my car as long as I want with moderate neck pain 3 - I can't drive my car as long as I want because of moderate pain 4 - I can hardly drive my car at all because of severe pain 5 - I can't drive my car at all

Submit

Proudly powered by Weebly

Home
Physical Therapy
Sports Performance
- Golf
- Running
- Throwing
- Hitting
Group Fitness
- Class Schedule
- Runner's Group
INFO
- Location
- News
- Blog
Golf Simulator