Neck Pain or Headaches Questionnaire

Welcome to Resolution Physiotherapy & IMS Clinic and thank you for choosing our team of Physiotherapists to help resolve your pain. We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

Please complete this questionnaire if our Physiotherapists are treating you for neck pain or headaches.

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Please enter today's date.

Date / Time

Question Title

* 3. This questionnaire has been designed to give us 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 that applies to you.

We realise you may consider that two or more statements in any one section relate to you, but please just mark the box that most closely describes your problem.

Section 1: Pain Intensity

Question Title

* 4. Section 2: Personal Care (Washing, Dressing, etc.)

Question Title

* 5. Section 3: Lifting

Question Title

* 6. Section 4: Reading

Question Title

* 7. Section 5: Headaches

Question Title

* 8. Section 6: Concentration

Question Title

* 9. Section 7: Work

Question Title

* 10. Section 8: Driving

Question Title

* 11. Section 9: Sleeping

Question Title

* 12. Section 10: Recreation

Question Title

* 13. Interpretation of scores (for office use only)

Score: (add up all of the scores) = _______                  
MDC (90% confidence): 5 points                          SCORE RANGE = 0 (no disability) to 50 (max disability)

NDI developed by: Vernon, H. & Mior, S. (1991). The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics. 14, 409-415

T