Client No.

: __________ Age: _____ Sex: M(__) F(__) Date: _______________

 TSK
Client No.:____________ Age: ______ Sex: M(__) F(__) Date:______

Somewhat disagree
Strongly disagree

Somewhat agree
Instructions

Strongly agree
Please read each of the following statements and circle the
number that better represents your feelings

1. I’m afraid that I might injure myself if I exercise ……………... 1 2 3 4

2. If I were to try to overcome it, my pain would increase ……….. 1 2 3 4

3. My body is telling me I have something dangerously wrong ….. 1 2 3 4

4. People aren’t taking my medical condition seriously enough …. 1 2 3 4

5. My accident has put my body at risk for the rest of my life …… 1 2 3 4

6. Pain always means I have injured my body …………………… 1 2 3 4

7. Simply being careful that I do not make any unnecessary

movements is the safest thing I can do to prevent my pain from
worsening ……………………………………………………..... 1 2 3 4

8. I wouldn’t have this much pain if there weren’t something

potentially dangerous going on in my body …………………… 1 2 3 4

9. Pain lets me know when to stop exercising so that I don’t injure

myself ………………………………………………………….. 1 2 3 4

10. I can’t do all the things normal people do because it’s too easy
for me to get injured ……………………………….................... 1 2 3 4

11. No one should have to exercise when he/she is in pain ………... 1 2 3 4



 Office Use Only
NECK DISABILITY INDEX
Name ________________________

Date ________________________

This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer
every section and mark in each section only the one box that applies to you. We realise you may consider that two or more statements in any one section
relate to you, but please just mark the box that most closely describes your problem.
Section 1: Pain Intensity Section 4: Reading
I have no pain at the moment I can read as much as I want to with no pain in my neck
The pain is very mild at the moment I can read as much as I want to with slight pain in my neck
The pain is moderate at the moment I can read as much as I want with moderate pain in my neck
The pain is fairly severe at the moment I can’t read as much as I want because of moderate pain in my neck
The pain is very severe at the moment I can hardly read at all because of severe pain in my neck
The pain is the worst imaginable at the moment I cannot read at all
Section 2: Personal Care (Washing,Dressing,etc.) Section 5: Headaches
I can look after myself normally without causing extra pain I have no headaches at all
I can look after myself normally but it causes extra pain I have slight headaches which come infrequently
It is painful to look after myself and I am slow and careful I have moderate headaches which come infrequently
I need some help but can manage most of my personal care I have moderate headaches which come frequently
I need help every day in most aspects of self care I have severe headaches which come frequently
I do not get dressed, I wash with difficulty and stay in bed I have headaches almost all the time
Section 3: Lifting Section 6: Concentration
I can lift heavy weights without extra pain I can concentrate fully when I want to with no difficulty
I can lift heavy weights but it gives extra pain I can concentrate fully when I want to with slight difficulty
Pain prevents me lifting heavy weights off the floor, but I I have a fair degree of difficulty in concentrating when I want to
can manage if they are conveniently placed, for example on a table I have a lot of difficulty in concentrating when I want to
Pain prevents me from lifting heavy weights but I can manage I have a great deal of difficulty in concentrating when I want to
light to medium weights if they are conveniently positioned I cannot concentrate at all
I can only lift very light weights
I cannot lift or carry anything Section 7: Work
 I can do as much work as I want to Section 9: Sleeping
I can only do my usual work, but no more I have no trouble sleeping
I can do most of my usual work, but no more My sleep is slightly disturbed (less than 1 hr sleepless)
I cannot do my usual work My sleep is mildly disturbed (1-2 hrs sleepless)
I can hardly do any work at all My sleep is moderately disturbed (2-3 hrs sleepless)
I can’t do any work at all My sleep is greatly disturbed (3-5 hrs sleepless)
My sleep is completely disturbed (5-7 hrs sleepless)
Section 8: Driving
I can drive my car without any neck pain Section 10: Recreation
I can drive my car as long as I want with slight pain in my neck I am able to engage in all my recreation activities with no neck pain at all
I can drive my car as long as I want with moderate pain in my neck I am able to engage in all my recreation activities, with some pain in my
I can’t drive my car as long as I want because of moderate pain in my neck
neck I am able to engage in most, but not all of my usual recreation activities
I can hardly drive at all because of severe pain in my neck because of pain in my neck
I can’t drive my car at all I am able to engage in a few of my usual recreation activities because of
pain in my neck
I can hardly do any recreation activities because of pain in my neck
I can’t do any recreation activities at all

Score: /50 Transform to percentage score x 100 = %points

Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last statement is marked it = 5. If all ten
sections are completed the score is calculated as follows: Example:16 (total scored)
50 (total possible score) x 100 = 32%

If one section is missed or not applicable the score is calculated:

16 (total scored)
45 (total possible score) x 100 = 35.5%
Minimum Detectable Change (90% confidence): 5 points or 10 %points

Reprinted from Journal of Manipulative and Physiological Therapeutics, 14, Vernon, H., & Mior, S., The Neck Disability Index: a study of reliability and validity, 409-415, 1991, with
permission from Elsevier.
 Copyright 1995
Michael JL Sullivan

PCS
Client No.: __________ Age: _____ Sex: M(__) F(__) Date: _______________

Everyone experiences painful situations at some point in their lives. Such experiences may include
headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause
pain such as illness, injury, dental procedures or surgery.

We are interested in the types of thoughts and feelings that you have when you are in pain. Listed
below are thirteen statements describing different thoughts and feelings that may be associated with
pain. Using the following scale, please indicate the degree to which you have these thoughts and
feelings when you are experiencing pain.

0 – not at all 1 – to a slight degree 2 – to a moderate degree 3 – to a great degree 4 – all the time

When I’m in pain …

1 I worry all the time about whether the pain will end.

2 I feel I can’t go on.

3 It’s terrible and I think it’s never going to get any better.

4 It’s awful and I feel that it overwhelms me.

5 I feel I can’t stand it anymore.

6 I become afraid that the pain will get worse.

7 I keep thinking of other painful events.

8 I anxiously want the pain to go away.

9 I can’t seem to keep it out of my mind.

10 I keep thinking about how much it hurts.

11 I keep thinking about how badly I want the pain to stop.

12 There’s nothing I can do to reduce the intensity of the pain.

13 I wonder whether something serious may happen.

…Total