Skip to content

OCEAN PINES 410-208-3300
SALISBURY 410-742-3300

About
- About Us
- Reviews
- Meet The Team
- FAQ
- Gallery
- Body & Mind Blog
Services
Contact / Directions
Patient Portal

REQUEST APPOINTMENT

Home » Patient Portal » Neck Disability Form

SALISBURY 410-742-3300
OCEAN PINES 410-208-3300

Patient Portal

Neck Disability Form
Quick Dash Form
Medication List Form
Our Services
Low Back Pain and Disability Index Form
Lower Extremity Functional Index Form
Info and FAQ
Direct Access
Welcome Letter

Neck Disability Form

If you prefer not to use our online form, you can hit the button below to open the .pdf and print for your visit.

.PDF DOWNLOAD/PRINT

Step 1 of 6

16%

PLEASE READ CAREFULLY: This questionnaire has been designed to give the doctor information as to how your lneck pain has affected your ability to manage everyday life. Please read all statements in each section and mark the circle which most describes your problem.
Name*
First Last
Date*
MM slash DD slash YYYY
Phone
Email*

SECTION 1: PAIN INTENSITY*
- 0. The pain comes and goes and is very mild.
- 1. The pain is mild and does not vary much.
- 2. The pain comes and goes and is moderate.
- 3. The pain is moderate and does not vary much.
- 4. The pain comes and goes and is very severe.
- 5. The pain is severe and does not vary much.
SECTION 2: PERSONAL CARE*
- 0. I can look after myself normally without causing extra neck pain.
- 1. I can look after myself normally, but it causes extra neck 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 my self-care.
- 5. I do not get dressed. I wash with difficulty and stay in bed.
SECTION 3: LIFTING*
- 0. I can lift heavy weights without causing extra neck pain.
- 1. I can lift heavy weights, but it gives me extra pain.
- 2. Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.
- 3. Neck pain prevents me from lifting heavy weights but I can manage light weights if they are conveniently positioned.
- 4. I can lift only very light weights.
- 5. I cannot lift or carry anything at all.

SECTION 4: READING*
- 0. I can lift heavy weights without causing extra neck pain.
- 1. I can lift heavy weights, but it gives me extra pain.
- 2. Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table.
- 3. Neck pain prevents me from lifting heavy weights but I can manage light weights if they are conveniently positioned.
- 4. I can lift only very light weights.
- 5.I cannot lift or carry anything at all.
SECTION 5: HEADACHES*
- 0. I have no headaches at all.
- 1. I have slight headaches that come infrequently.
- 2. I have moderate headaches that come infrequently.
- 3. I have moderate headaches that come frequently.
- 4. I have severe headaches that come frequently.
- 5. I have headaches almost all the time.
SECTION 6: CONCENTRATION*
- 0. I can concentrate fully without difficulty.
- 1. I can concentrate fully with slight difficulty.
- 2. I have a fair degree of difficulty concentrating
- 3. I have a lot of difficulty concentrating.
- 4. I have a great deal of difficulty concentrating.
- 5. I can’t concentrate at all.

SECTION 7: WORK*
- 0. I can do as much work as I want.
- 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 can’t do my usual work.
- 4. I can hardly do any work at all.
- 5. I can’t do any work at all.
SECTION 8: DRIVING*
- 0. I can drive my car without neck pain.
- 1. I can drive my car with only slight neck pain.
- 2.I can drive as long as I want with moderate neck pain.
- 3. I can’t drive as long as I want because of moderate neck pain.
- 4. I can hardly drive at all because of severe neck pain.
- 5.I can’t drive my car at all because of neck pain.
SECTION 9: SLEEPING*
- 0. I have no trouble sleeping.
- 1. My sleep is slightly disturbed for less than 1 hour.
- 2. My sleep is mildly disturbed for up to 1-2 hours.
- 3. My sleep is moderately disturbed for up to 2-3 hours.
- 4. My sleep is greatly disturbed for up to 3-5 hours.
- 5. MMy sleep is completely disturbed for up to 5-7 hours.
SECTION 10: RECREATION*
- 0. I am able to engage in all recreational activities with no neck pain at all.
- 1. I am able to engage in all my recreational activities with some neck pain.
- 2. I am able to engage in most, but no all of my recreational activities because of pain in my neck.
- 3. I am able to engage in a few of my recreational activities because of neck pain.
- 4. I can hardly do recreational activities due to neck pain.
- 5. I can’t do any recreational activities due to neck pain.

Score out of 40 - ADMIN
NECK PAIN SCALE*
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
RATE YOUR PAIN ON A SCALE OF 0 - 10. 0 = ABSENCE OF PAIN 10 - EXTREME OPAIN
Comment

Signature
Date
CAPTCHA

BERLIN

11007 Manklin Creek Rd, Unit 5
Berlin, MD 21811

Phone Number
410-208-3300

Fax Number
443-513-3958

Call Us: 410-208-3300

SALISBURY

119 West College Ave Suite 205 Salisbury, MD 21804

Phone Number
410-742-3300

Fax Number
410-742-4040

Copyright 2024 © HAMILTON PHYSICAL THERAPY

About
- About Us
- Reviews
- Meet The Team
- FAQ
- Gallery
- Body & Mind Blog
Services
Contact / Directions
Patient Portal
PROMOTIONSff