*****This is a simulation page and no data will be transmitted.*****
NDI Disability Index
After you select the name of the provider you are scheduled to see, the health form will be displayed.
Please select the name of the doctor you are scheduled to see.
My provider is not in the list
---------- Date of Birth ----------
First Name
Last Name
Month
Day
Year
Gender
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Male
Female
Your provider is not in the list of providers above. You will need to notify the clinic that your provider is not in the list.
In order to notify the clinic, please enter your name and other demographic information above and enter the name
of your provider below. The clinic will be notified that the provider's name is missing.
Provider Name
This questionnaire has been designed to give the doctor information as to how your neck problems have affected your ability to manage in everyday life.
Please answer every section and mark in each section ONLY THE ONE which applies to you.
We realize you may consider that two of the statements in any one section relate to you.
PLEASE JUST MARK THE ONE WHICH MOST CLEARLY DESCRIBES YOUR PROBLEM.
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.
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'm slow and careful.
I need some help but can 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.
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 if conveniently placed, for example 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 only lift very light weights.
I cannot lift or carry anything.
Reading
I can read as much as I want 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.
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.
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.
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.
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.
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 disturbed).
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.
Back
Next
IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.