Neck and Upper Back Questionnaire

NECK PAIN DISABILITY INDEX QUESTIONNAIRE 

PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section by checking the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CHECK THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW. 

SECTION 1 - Pain Intensity:
SECTION 2 - Personal Care (washing, dressing, etc.):
SECTION 3 - Lifting:
SECTION 4 - Reading:
SECTION 5 - Headaches:
SECTION 6 - Concentration:
SECTION 7 - Work:
SECTION 8 - Driving:
SECTION 9 - Sleeping:
SECTION 10 - Recreation:

Thank you for taking the time to fill out this form.

CONTACT US TODAY

We look forward to hearing from you

Location

Find us on the map

Office Hours

Our Regular Schedule

Arlington Chiropractic

Monday:

9:00 am-7:00 pm

Tuesday:

8:30 am-7:00 pm

Wednesday:

9:00 am-7:00 pm

Thursday:

9:00 am-7:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

8:00 am-1:00 pm

Sunday:

Closed