Patient Form
NECK PAIN DISABILITY INDEX QUESTIONNAIRE
Innovative Physical Therapy LLC
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PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each question by selecting the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST SELECT THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.
Section 1: Pain Intensity
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
Section 2: Personal Care (Washing, Dressing, etc.)
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
Section 3: Lifting
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
Section 4: Reading
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
Section 5: 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 headaches almost all the time
Section 6: Concentration
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
Section 7: Work
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
Section 8: Driving
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
Section 9: Sleeping
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)
Section 10: Recreation
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
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