Neck Pain Disability Index (Vernon-Mior) Form (Page 3 of 3) in pdf

Neck Pain Disability Index (Vernon-Mior) Form Page 3

Section 6 - Concentration

NDI

† I can concentrate fully when I want with no difficulty

† I can concentrate fully when I want to with slight difficulty

† I have a fair degree of difficulty concentrating when I want to

† I have a lot of difficulty concentrating when I want to

† I have a great deal of difficulty concentrating when I want to

† I cannot concentrate at all

Section 7 - Work

† I can do as much work as I want

† I cannot do my usual work

† I can only do my usual work, but no more

† I can hardly do any work at all

† I can do most of my usual work, but no more

† I cannot do any work at all

Section 8 - Driving

† I can drive my car without any neck pain

† I can drive my car as long as I want with slight neck pain

† I can drive my car as long as I want with moderate neck pain

† 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 neck pain

† I can’t drive my car at all

Section 9 - Sleeping

† I have no trouble sleeping

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

† My sleep is mildly disturbed (1 to 2 hours sleepless)

† My sleep is moderately disturbed (2 to 3 hours sleepless)

† My sleep is greatly disturbed ( 3 to 5 hours sleepless)

† My sleep is completely disturbed (5 to 7 hours sleepless)

Section 10 - Recreation

† I am able to engage in all my recreation activities with no neck pain

† I am able to engage in all my recreation activities with some neck pain

† I am able to engage in most, but not all, of my usual recreation activities because of neck pain

† I am able to engage in a few of my usual recreation activities because of neck pain

† I can hardly do any recreation activities because of neck pain

† I can’t do any recreation activities at all because of neck pain

Pain scale

Rate the severity of your pain by checking one box of the scale

No pain

Excruciating pain

Neck Disability Index

Page 3 of 3

Neck Pain Disability Index (Vernon-Mior) Form Page 3