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Neck disability index

1
Neck Disability Index
Instructions This questionnaire has been designed to give your health practitioner information as to how your neck pain has affected your ability to manage in everyday life.
Please answer every section and mark in each section only the ONE box which applies to you. We realise you may consider that two of the statements in any one section relate to you, but please just mark the box which most closely describes your problem.
Section 1 – Pain intensityselect one
Section 2 – Personal care (washing, dressing)select one
Section 3 – Liftingselect one
Section 4 – Readingselect one
Section 5 – Headachesselect one
Section 6 – Concentrationselect one
Section 7 – Workselect one
Section 8 – Drivingselect one
Section 9 – Sleepingselect one
Section 10 – Recreationselect one
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  • Forms
  • Allied Health Patient Contact Details Form
  • Allied Health Medical History & General Health
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Medical History & General Health
MEDICAL HISTORY AND GENERAL HEALTH FORM
Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form.
Are your symptoms worse during the day or at night
Does your pain wake you at night?
Did you find the treatment effective?
Could you be pregnant?Females only
Does your current problem involve any of the following:
YesNo
Pain in either arm and leg
Tingling in either arm and leg
Numbness in either arm and leg
Weakness in either arm and leg
"Weird" sensations in either arm and leg
Does your current problem involve any of the following:
YesNo
Do you currently smoke?
Do you currently drink alcohol?
Do you currently take recreational drugs?
Do you think you have a healthy diet?
Do you take vitamin supplements?
Do you exercise regularly?
Please indicate yes/no to the following
YesNo
Do you have frequent headaches?
Do you feel stressed?
Have you experienced dizziness /vertigo /faints/blackouts?
Do you suffer from fatigue?
Do you suffer from night sweats/fever?
Do your joints swell?
Have you lost/gained weight in the past year?
Do you have digestive problems?
Have you noticed any blood or mucus in your bowel movements?
Do you suffer from shortness of breath or chest pain on exertion?
Do you have any pain or increased frequency on passing urine?
Do you have any unusual lumps/swelling on your body?
Do you have any problems with hearing? (Including ringing in ears)
Do you have any problems with smell or taste?
Are you easily depressed?
Do you suffer from anxiety?
Do you have poor sleep?
Do you have any problems with your vision?
Do you have poor balance?
I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.
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