Narendra Kansal, MD

NAME *

DATE *

Please read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please answer each section circling 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 CIRCLE THE ONE CHOICE THAT MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. At the end of this questionnaire you need to ADD UP YOUR CIRCLED NUMBERS TO MAKE A SCORE and put that number in the space provided below.

SECTION A

PAIN INTENSITY *

0. I have no pain at the moment

1. The pain is mild at the moment.

2. The pain comes and goes and is moderate.

3. The pain is moderate and does not vary much.

4. The pain is severe but comes and goes.

5. The pain is severe and does not vary much.

SECTION B

PERSONAL CARE (WASHING, DRESSING) *

0. I can look after myself without causing extra pain.

1. I can look after myself normally but it causes extra pain.

2. It is painful to look after myself and I am slow and careful.

3. I need some help, but manage most of my personal care.

4. I need help every day in most aspects of self-care.

5. I do not get dressed; I wash with difficulty and stay in bed.

SECTION C

LIFTING *

SECTION D

READING *

0. I can read as much as I want to with no pain in my neck.

1. I can read as much as I want with slight pain in my neck.

2. I can read as much as I want with moderate pain in my

neck.

3. I cannot read as much as I want because of moderate pain

in my neck.

4. I cannot read as much as I want because of severe pain in

my neck.

5. I cannot read at all.

SECTION E

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 frequently.

5. I have headaches almost all the time.

SECTION F

CONCENTRATION *

0. I can concentrate fully when I want to with no difficulty.

1. I can concentrate fully when I want to with slight difficulty.

2. I have a fair degree of difficulty in concentrating when I want

to.

3. I have a lot of difficulty in concentrating when I want to.

4. I have a great deal of difficulty in concentrating when I want

to.

5. I cannot concentrate at all.

SECTION G

WORK *

0. I can do as much work 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 work at all.

5. I cannot do any work at all.

SECTION H

DRIVING *

0. I can drive my car without neck pain.

1. I can drive my car as long as I want with slight pain in my neck.

2. I can drive my car as long as I want with moderate pain in my neck.

3. I cannot drive my car as long as I want because of moderate pain in my neck.

4. I can hardly drive my car at all because of severe pain in my neck.

5. I cannot drive my car at all.

SECTION I

SLEEPING *

0. I have no trouble sleeping

1. My sleep is slightly disturbed (less than 1 hour sleepless).

2. My sleep is mildly disturbed (1-2 hours sleepless).

3. My sleep is moderately disturbed (2-3 hours sleepless).

4. My sleep is greatly disturbed (3-5 hours sleepless).

5. My sleep is completely disturbed (5-7 hours sleepless).

SECTION J

RECREATION *

0. I am able engage in all recreational activities with no pain in my neck at all.

1. I am able engage in all recreational activities with some pain in my neck.

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

3. I am able engage in a few of my usual recreational activities because of pain in my neck.

4. I can hardly do any recreational activities because of pain in my neck.

5. I cannot do any recreational activities all.

disability index:

for office staff only

HOW LONG HAVE YOU HAD YOUR SYMPTOMS? *

please put how many days, weeks, months or years.

Please check the box that corresponds to the pain level that you are experiencing.

MY PAIN WHEN IT IS AT ITS WORST IS: *

MY PAIN RIGHT NOW IS *

MY AVERAGE PAIN LEVEL IS *

Available Forms

NECK DISABILITY FORM

SECTION A

SECTION B

SECTION C

SECTION D

SECTION E

SECTION F

SECTION G

SECTION H

SECTION I

SECTION J