Neck Disability Index Form (NDI) - Progressive Physical Therapy

PLEASE DO NOT PRINT THIS FORM. Your responses help your provider determine the best treatment options to track your recovery progress over time. Please answer each of the questions included on this form. Thank you for completing this patient-reported outcome questionnaire.

ALL QUESTIONS MUST BE ANSWERED

Name *

First

Middle

Last

Today's Date : *

Did you have surgery for this issue PRIOR TO receiving Physical Therapy? *

Yes
No

PAIN SCORE: Over the past 24 hours, how bad has your pain been? *

Select the number that best describes your pain. 0 = No Pain, 10 = Worst Pain imaginable.

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 the worst imaginable at the moment.

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 manage most aspects of self-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.

3. LIFTING: *

I can lift heavy weights without increased pain.
I can lift heavy weights, but it causes increased pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if the weights are conveniently positioned (e.g. on a table – etc.).
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.

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.

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 of the time.

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 concentrating when I want to.
I have a great deal of difficulty in concentrating when I want to.
I cannot concentrate at all.

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.

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.

9. SLEEPING: *

I have no trouble sleeping.
My sleep is slightly disturbed (Less than 1 hour sleep loss).
My sleep is mildly disturbed (1-2 hour sleep loss).
My sleep is moderately disturbed (2-3 hour sleep loss).
My sleep is greatly disturbed (3-5 hour sleep loss).
My sleep is completely disturbed (5-7 hour sleep loss).

10. RECREATION *

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 neck pain.
I am able to engage in most but not all of my recreational activities because of pain in my neck.
I am able to engage in few of my 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.