Instructions:
This questionnaire has been designed to give your therapist information as to how your neck pain is affecting your ability to manage everyday activities. Please mark ONE answer in each section
that most closely describes your situation TODAY. Although you may feel that two of the statements apply to you, please mark only the ONE that most closely describes your situation.
1. Pain Intensity
A. No pain at the moment.
B. The pain is very mild at the moment.
C. The pain is moderate at the moment.
D. The pain is fairly severe at the moment.
E. The pain is very severe at the moment.
F. The pain is the worst imaginable at the moment.
2. Personal Care (Washing, Dressing, etc.)
A. I can look after myself normally without causing extra pain.
B. I can look after myself normally but it causes extra pain.
C. It is painful to look after myself and I am slow and careful.
D. I need some help but manage most of my personal care.
E. I need help every day in most aspects of self-care.
F. I do not get dressed, I wash with difficulty, and I stay in bed.
3. Lifting
A. I can lift heavy weights without extra pain.
B. I can lift heavy weights but it gives extra pain.
C. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned.
D. Pain prevents me from lifting heavy weights but I can manage light to medium weights if conveniently positioned.
E. I can lift only very light weights.
F. I cannot lift or carry anything.
4. Reading
A. I can read as much as I want with no pain in my neck.
B. I can read as much as I want with slight pain in my neck.
C. I can read as much as I want with moderate pain in my neck.
D. I cannot read as much as I want because of moderate pain in my neck.
E. I can hardly read at all because of severe pain in my neck.
F. I cannot read at all.
5. Headaches
A. I have no headaches at all.
B. I have slight headaches which come infrequently.
C. I have moderate headaches which come infrequently.
D. I have moderate headaches which come frequently.
E. I have severe headaches which come frequently.
F. I have headaches almost all the time.
6. Concentration
A. I can concentrate fully when I want to with no difficulty.
B. I can concentrate fully when I want to with slight difficulty.
C. I have a fair degree of difficulty concentrating when I want to.
D. I have a lot of difficulty concentrating when I want to.
E. I have a great deal of difficulty concentrating when I want to.
F. I cannot concentrate at all.
7. Work
A. I can do as much work as I want to.
B. I can only do my usual work, but no more.
C. I can do most of my usual work, but no more.
D. I cannot do my usual work.
E. I can hardly do any work at all.
F. I cannot do any work at all.
8. Driving
A. I can drive my car without any neck pain.
B. I can drive my car as long as I want with slight pain in my neck.
C. I can drive my car as long as I want with moderate pain in my neck.
D. I cannot drive my car as long as I want because of moderate pain in my neck.
E. I can hardly drive at all because of severe pain in my neck.
F. I cannot drive my car at all.
9. Sleeping
A. I have no trouble sleeping.
B. My sleep is slightly disturbed (less than 1 hour sleepless).
C. My sleep is mildly disturbed (1–2 hours sleepless).
D. My sleep is moderately disturbed (2–3 hours sleepless).
E. My sleep is greatly disturbed (3–5 hours sleepless).
F. My sleep is completely disturbed (5–7 hours sleepless).
10. Recreation
A. I am able to engage in all my recreation activities with no neck pain.
B. I am able to engage in all my recreation activities with some pain in my neck.
C. I am able to engage in most, but not all, of my usual recreation activities because of pain in my neck.
D. I am able to engage in a few of my usual recreation activities because of pain in my neck.
E. I can hardly do any recreation activities because of pain in my neck.
F. I cannot do any recreation activities at all.
✓ End of Patient Questionnaire
Thank you for completing this questionnaire. Please return this form to your therapist.
🔒 CLINICIAN USE ONLY — Complete the score fields below after the patient finishes this questionnaire.
Score Range
Classification
0 – 4 (0–8%)
No disability
5 – 14 (10–28%)
Mild disability
15 – 24 (30–48%)
Moderate disability
25 – 34 (50–64%)
Severe disability
35 – 50 (70–100%)
Complete disability
Source: Vernon H, Mior S. J Manipulative Physiol Ther. 1991;14(7):409–415. © Howard Vernon. Free for clinical use. MCID: 7.5 points or 15%.
