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 by 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
which closely describes your problem right now.
SECTION 1--Pain Intensity SECTION 6 -- Concentration
A. I have no pain at the moment A. I can concentrate fully when I want to with no difficulty.
B. The pain is mild at the moment. B. I can concentrate fully when I want to with slight difficulty.
C. The pain comes and goes and is moderate. C. I have a fair degree of difficulty in concentrating when I
D. The pain is moderate and does not vary much. want to.
E. The pain is severe but comes and goes. D. I have a lot of difficulty in concentrating when I want to.
F. The pain is severe and does not vary much. E. I have a great deal of difficulty in concentrating when I want
to.
SECTION 2--Personal Care (Washing, Dressing etc.)
F. I cannot concentrate at all.
A. I can look after myself without causing extra pain.
B. I can look after myself normally but it causes extra pain. SECTION 7--Work
C. It is painful to look after myself and I am slow and careful. A. I can do as much work as I want to.
D. I need some help, but manage most of my personal care. B. I can only do my usual work, but no more.
E. I need help every day in most aspects of self-care. C. I can do most of my usual work, but no more.
F. I do not get dressed, I wash with difficulty and stay in bed. D. I cannot do my usual work.
E. I can hardly do any work at all.
SECTION 3--Lifting
F. I cannot do any work at all.
A. I can lift heavy weights without extra pain.
B. I can lift heavy weights, but it causes extra pain. SECTION 8--Driving
C. Pain prevents me from lifting heavy weights off the floor but A. I can drive my car without neck pain.
I can if they are conveniently positioned, for example on a B. I can drive my car as long as I want with slight pain in my
table. neck.
D. Pain prevents me from lifting heavy weights, but I can C. I can drive my car as long as I want with moderate pain in
manage light to medium weights if they are conveniently my neck.
positioned. D. I cannot drive my car as long as I want because of moderate
E. I can lift very light weights. pain in my neck.
F. I cannot lift or carry anything at all. E. I can hardly drive my car at all because of severe pain in my
neck.
SECTION 4 --Reading
F. I cannot drive my car at all.
A. I can read as much as I want to with no pain in my neck.
B. I can read as much as I want with slight pain in my neck. SECTION 9--Sleeping
C. I can read as much as I want with moderate pain in my neck. A. I have no trouble sleeping
D. I cannot read as much as I want because of moderate pain in B. My sleep is slightly disturbed (less than 1 hour sleepless).
my neck. C. My sleep is mildly disturbed (1-2 hours sleepless).
E. I cannot read as much as I want because of severe pain in my D. My sleep is moderately disturbed (2-3 hours sleepless).
neck. E. My sleep is greatly disturbed (3-5 hours sleepless).
F. I cannot read at all. F. My sleep is completely disturbed (5-7 hours sleepless).
SECTION 5--Headache SECTION 10--Recreation
A. I have no headaches at all. A. I am able engage in all recreational activities with no pain in
B. I have slight headaches which come infrequently. my neck at all.
C. I have moderate headaches which come in-frequently. B. I am able engage in all recreational activities with some pain
D. I have moderate headaches which come frequently. in my neck.
E. I have severe headaches which come frequently. C. I am able engage in most, but not all recreational activities
F. I have headaches almost all the time. because of pain in my neck.
D. I am able engage in a few of my usual recreational activities
because of pain in my neck.
E. I can hardly do any recreational activities because of pain in
my neck.
F. I cannot do any recreational activities all all.
SIGNATURE: DATE:
© Vernon H and Hagino C, 1991
(with permission from Fairbank J)

DISABILITY INDEX SCORE: %

NAME DATE

How long have you had neck pain years months weeks

On the diagram below, please indicate where you are experiencing pain or other symptoms,
right now. Please complete both sides of this form.

A = ACHE B = BURNING N = NUMBNESS