ࡱ> Z\Yq` bjbjqPqP 7H::VVVVVVVjtF<j #RF|"~"~"~"~"~"~"$#h]&"!Vrrr"VV"!!!rVV|"!r|"!!VV! P^hiF!!"0 #!&&!&V!LB"d!|BBB""! BBB #rrrrjjjD $jjjjjjVVVVVV Office Use: Therapist:______ The Oswestry Neck Disability Index (Confidential) Score: ________ Patient Name:  FORMTEXT       Date: FORMTEXT       Please check only ONE statement in each section that describes how youre feeling TODAY Section 1 Pain Intensity  FORMCHECKBOX  I have no pain at the moment.  FORMCHECKBOX  Pain is very mild at the moment.  FORMCHECKBOX  Pain is moderate at the moment.  FORMCHECKBOX  Pain is fairly severe at the moment.  FORMCHECKBOX  Pain is very severe at the moment.  FORMCHECKBOX  Pain is the worst imaginable at the moment.Section 6 Concentration  FORMCHECKBOX I can concentrate fully when I want to with no difficulty.  FORMCHECKBOX I can concentrate fully when I want to with slight difficulty.  FORMCHECKBOX I have a fair degree of difficulty in concentrating.  FORMCHECKBOX I have a lot of difficulty in concentrating when I want to.  FORMCHECKBOX I have a great deal of difficulty in concentrating.  FORMCHECKBOX I cannot concentrate at all.Section 2 Personal Care (Washing, Dressing, etc)  FORMCHECKBOX  I can look after myself normally without causing extra pain.  FORMCHECKBOX  I can look after myself normally but it causes extra pain.  FORMCHECKBOX  It is painful to look after myself and I am slow and careful.  FORMCHECKBOX  I need some help but manage most of my personal care.  FORMCHECKBOX  I need help every day in most aspects of self car.  FORMCHECKBOX  I do not get dressed. I wash with difficulty and stay in bed.Section 7 Work  FORMCHECKBOX I can work as much as I want to.  FORMCHECKBOX I can only do my usual work but no more.  FORMCHECKBOX I can do most of my usual work but no more.  FORMCHECKBOX I cannot do my usual work.  FORMCHECKBOX I can hardly do any work at all.  FORMCHECKBOX I cannot do any work at all.Section 3 Lifting  FORMCHECKBOX I can lift heavy weights without extra pain.  FORMCHECKBOX I can lift heavy weights but it gives extra pain.  FORMCHECKBOX I can lift heavy weight items if conveniently .positioned.  FORMCHECKBOX I can lift light/medium weights if conveniently positioned.  FORMCHECKBOX I can lift very light weights.  FORMCHECKBOX I cannot lift or carry anything at all.Section 8 Driving  FORMCHECKBOX I can drive my car without any neck pain.  FORMCHECKBOX I can drive my car as desired with light neck pain.  FORMCHECKBOX I can drive my car as desired with moderate neck pain.  FORMCHECKBOX I cannot drive my car much because of moderate neck pain.  FORMCHECKBOX I can hardly drive at all because of severe pain in my neck.  FORMCHECKBOX I cant drive my car at all.Section 4 Reading  FORMCHECKBOX I can read as much as I want to with no pain in my neck.  FORMCHECKBOX I can read as much as I want to with slight pain in my neck.  FORMCHECKBOX I can just read as much as I want with moderate neck pain.  FORMCHECKBOX I cannot read as much because of moderate neck pain.  FORMCHECKBOX I can hardly read at all because of severe pain in my neck.  FORMCHECKBOX I cannot read at all.Section 9 - Sleeping  FORMCHECKBOX I have no trouble sleeping.  FORMCHECKBOX My sleep is mildly disturbed (less than 1 hour sleepless).  FORMCHECKBOX My sleep is mildly disturbed (1-2 hours sleepless).  FORMCHECKBOX My sleep is moderately disturbed (2-3 hours sleepless).  FORMCHECKBOX My sleep is greatly disturbed (3-5 hours sleepless).  FORMCHECKBOX My sleep is completely disturbed (5-7 hours sleepless).Section 5 Headaches  FORMCHECKBOX I have no headaches at all.  FORMCHECKBOX I have slight headaches which come infrequently.  FORMCHECKBOX I have moderate headaches which come infrequently.  FORMCHECKBOX I have moderate headaches which come frequently.  FORMCHECKBOX I have severe headaches which come frequently.  FORMCHECKBOX I have headaches almost all the time.Section 10 - Recreation  FORMCHECKBOX I can engage in all my recreational activities with no neck pain at all.  FORMCHECKBOX I can do all recreation activities with some neck pain.  FORMCHECKBOX I can do most, not all recreational activities with some neck pain.  FORMCHECKBOX I can do some recreational activities with neck pain.  FORMCHECKBOX I can hardly do recreational activities because of neck pain.  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