Neck Pain Questionnaire

Name *

First Name

Last Name

Can you sleep at night without neck pain interfering?

Yes

Occasionally

No

Can you manage daily activities without neck pain reducing activity levels?

Yes

Occasionally

No

Can you manage daily activities without help from others?

Yes

Occasionally

No

Can you manage putting on your clothes in the morning without taking more time than usual

Yes

Occasionally

No

Can you bend over the washing basin to brush your teeth without getting neck pain?

Yes

Occasionally

No

Do you spend more time than usual at home because of neck pain?

Yes

Occasionally

No

Are you prevented from lifting objects between 2-4kg due to neck pain?

Yes

Occasionally

No

Have you reduced your reading activity due to neck pain?

Yes

Occasionally

No

Have you been bothered by headaches during those times that you have neck pain?

Yes

Occasionally

No

Do you feel that your ability to concentrate is reduced due to back neck pain?

Yes

Occasionally

No

Are you prevented from participating in your usual leisure time activities due to back pain?

Yes

Occasionally

No

Do you remain in bed longer than usual due to back pain

Yes

Occasionally

No

Do you feel that neck pain has influenced your emotional relationship with your nearest family?

Yes

Occasionally

No

Have you had to give up social contact with other people during the past two weeks due to neck pain?

Yes

Occasionally

No

Do you feel that neck pain will influence your future?

Yes

Occasionally

No