Neck Functional Scale

Please fill out the following scale form as accurately as possible and upload with your new client form. If you would prefer to download the PDF of this form, please click the button below and upload it on our New Client Form page.

download

Neck Funtional Scale

This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please select the answers below that best apply.

Name *

First

Last

Email *

Date *

Please rate your pain level with activity

Selected Value: 0

0 = NO PAIN, 10 = VERY SEVERE PAIN

NECK DISABILITY INDEX - INITIAL VISIT

Pain Intensity *

(0) I have no pain at the moment.
(1) The pain is very mild at the moment.
(2) The pain is moderate at the moment.
(3) The pain is fairly severe at the moment.
(4) The pain is very severe at the moment.
(5) The pain is the worse imaginable at the moment.

Personal Care (washing, dressing, etc) *

(0) I can look after myself normally without extra pain.
(1) I can look after myself normally but it causes extra pain.
(2) It is painful to look after myself and I am slow and careful.
(3) I need some help but manage most of my personal care.
(4) I need help every day in most aspects of self care.
(5) I cannot get dressed, wash with difficulty and stay in bed.

Lifting *

(0) I can lift heavy weights without extra pain.
(1) I can lift heavy weights but it gives me extra pain.
(2) Pain prevents me from lifting heavy weights off the floor but I can manage if they are on a table.
(3) Pain prevents me from lifting heavy weights but I can manage if they are conveniently placed.
(4) I can lift only very light weights.
(5) I cannot lift or carry anything at all.

Headache *

(0) I have no headaches at all.
(1) I have slight headaches which come infrequently.
(2) I have moderate headaches which come infrequently.
(3) I have moderate headaches which come frequently.
(4) I have severe headaches which come infrequently.
(5) I have headaches almost all the time.

Recreation *

(0) I am able engage in all my recreational activities without pain.
(1) I am able to engage in my recreational activities with some pain.
(2) I am able to engage in most but not all of my usual recreational activities because of my neck pain.
(3) I am able to engage in a few of my usual recreational activities with some neck pain.
(4) I can hardly do any recreational activities because of neck pain.
(5) I can’t do any recreational activities at all.

Reading *

(0) I can read as much as I want with no pain in my neck. no headaches at all.
(1) I can read as much as I want with slight neck pain.
(2) I can read as much as I want with moderate neck pain.
(3) I can’t read as much as I want because of moderate neck pain.
(4) I can hardly read at all because of severe neck pain.
(5) I cannot read at all because of neck pain.

Work *

(0) I can do as much as I want to.
(1) I can only do my usual work but no more.
(2) I can do most of my usual work but no more.
(3) I cannot do my usual work.
(4) I can hardly do any usual work at all.
(5) I can’t do any work at all.

Sleeping *

(0) Pain does not prevent me from sleeping well.
(1) I can concentrate fully when I want with slight difficulty.
(2) I have a fair degree of difficulty concentrating when I want.
(3) I have a lot of difficulty concentrating when I want.
(4) I have great difficulty concentrating when I want.
(5) I cannot concentrate at all.

Concentration *

(0) I can concentrate fully when I want with no difficulty.
(1) I can only do my usual work but no more.
(2) I can do most of my usual work but no more.
(3) I cannot do my usual work.
(4) I can hardly do any usual work at all.
(5) I can’t do any work at all.

Driving *

(0) I can drive my car without neck pain.
(1) I can drive my car as long as I want with slight neck pain.
(2) I can drive my car as long as I want with moderate neck pain.
(3) I can’t drive my car as long as I want because of moderate pain.
(4) I can hardly drive my car at all because of severe neck pain.
(5) I can’t drive my car at all.

Neck Functional Scale

Neck Funtional Scale

NECK DISABILITY INDEX - INITIAL VISIT

We're here when you cannot wait to feel better.

Get In Touch Today!

Contact Info

Address

Hours

Conveniently located in Moorpark near 23 Freeway, just a few minutes from Thousand Oaks and Simi Valley.