Neck Disability Index

This survey is for patients who have had Cervical Spinal Surgery with Carle Spine Institute. These are the same surveys you took before surgery. Your surgeon would appreciate it if you would fill these out 3, 6, and 12 months after surgery so we can track your progress.


First

Last


MRN


Today's Date (M/D/Y)

 

If so, was it at the Spine Institute?

These questions pertain to your neck and related symptoms. Please answer each question and mark only ONE answer that best fits your situation.

How would you rate your average daily pain on a 0 to 10 scale?
1

2

3

4

5

6

7

8

9

10

Section 1 - Pain Intensity Section 6 - Concentration

I have no pain at the moment

I can concentrate fully when I want to, with no difficulty.

The pain is very mild at the moment

I can concentrate fully when I want to, with slight difficulty.

The pain is moderate at the moment

I have a fair degree of difficulty in concentrating when I want to.

The pain is fairly severe at the moment

I have a lot of difficulty in concentrating when I want to.

The pain is very severe at the moment

I have a great deal of difficulty in concentrating when I want to.

The is the worst imaginable at the moment

I cannot concentrate at all.

Section 2 - Personal Care (Washing, Dressing, etc.) Section 7 - Work

I can look after myself normally, without causing extra pain.

I can do as much work as I want to.

I can look after myself normally, but it causes extra pain.

I can do my usual work, but no more.

It is painful to look after myself and I am slow and careful.

I can do most of my usual work, but not more.

I need some help, but manage most of my personal care.

I cannot do my usual work.

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

I can hardly do any work at all.

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

I can't do any work at all.

Section 3 - Lifting Section 8 - Driving

I can lift heavy weights without extra pain.

I can drive my car without any neck pain.

I can lift heavy weights, but it gives extra pain.

I can drive my car as long as I want, with slight pain in my neck.

Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example, on a table.

I can drive my car as long as I want, with moderate pain in my neck.

Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

I can drive my car as long as I want, because of moderate pain in my neck.

I can lift very light weights.

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

I cannot lift or carry anything at all.

I can't drive my car at all.

Section 4 - Reading Section 9 - Sleeping

I can read as much as I want to, with no pain in my neck.

I have no trouble sleeping.

I can read as much as I want to, with slight pain in my neck.

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

I can read as much as I want to, with moderate pain in my neck.

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

I can't read as much as I want to, because of moderate pain in my neck.

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

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

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

I cannot read at all.

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

Section 5 - Headaches Section 10 - Recreation

I have no headaches at all.

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

I have slight headaches that come infrequently.

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

I have moderate headaches that come infrequently.

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

I have moderate headaches that come frequently.

I am able to engage in few of my recreation activities, because of pain in my neck.

I have severe headaches that come frequently.

I can hardly do any recreation activities, because of pain in my neck.

I have headaches almost all the time.

I can't do any recreation activities at all.

These questions pertain to your overall health, not just your Spine Surgery. Please answer each question and mark only ONE answer that best fits your situation.

In general, would you say your health is:

Excellent



Compared to one year ago, how would you rate your health in general now?






Yes, limited a lot
Yes, limited a little
Not limited at all

Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Lifting or carrying groceries

Climbing several flights of stairs

Climbing one flight of stairs

Bending, kneeling, or stooping

Walking more than a mile

Walking several hundred yards

Walking one hundred yards

Bathing or dressing yourself

All of the time
Most of the time
Some of the time
A little of the time
None of the time

Cut down on the amount of time you spent on work or other activities

Accomplished less than you would like

Did work or other activities less carefuly than usual

 
Not at all
Slightly
Moderately
Severe
Extremely
 
 
 
 
None
Very mild
Mild
Moderate
Severe
Very Severe
 
 
 
 
Not at all
A little bit
Moderately
Quite a bit
Extremely
 
 
 
All of the time
Most of the time
Some of the time
A little of the time
None of the time

Did you feel full of life?

Have you been very nervous?

Have you felt so down in the dumps that nothing could cheer you up?

Have you felt calm and peaceful?

Did you have a lot of energy?

Have you felt downhearted and depressed?

Did you feel worn out?

Have you been happy?

Did you feel tired?

 
All of the time
Most of the time
Some of the time
A little of the time
None of the time
 
 
 

How TRUE or FALSE is each of the following statements for you?

Definitely true

Mostly true

Don't know

Mostly false

Definitely false

I seem to get sick a little easier than other people

I am as healthy as anybody I know

I expect my health to get worse

My health is excellent

Thank you for completing these questions