The Orthopedic Center (NDI)

Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Cervical Disability Assessment

* Required Information

This questionnaire is designed to help us better understand how NECK PAIN affects your ability to manage in everyday life.

*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.

*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.

*Personal Care

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 of my personal care.

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

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

*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 can't do my usual work.

I can hardly do any work at all.

I can't do any work at all.

*Lifting

I can lift heavy weights without extra pain.

I can lift heavy weights but it gives extra pain.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. 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 lift only very light weights.

I cannot lift or carry anything at all.

*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 neck pain.

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

I can't drive my car at all.

*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 neck pain.

I can hardly read at all because of severe pain in my neck.

I cannot read at all.

*Sleeping

I have no trouble sleeping.

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

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

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

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

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

*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.

*Recreation

I am able to engage in all my recreation activities with no 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 only 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.