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Form 4 -
Neck problem form

Complete this form if you:

  • Have already been to Coogee Bay Physio (if not please complete form 1)

  • Have an issue with your shoulders, neck, arms, arm joints or hands.

About this form:

Neck disorders are a significant source of pain and activity limitation in workers and those involved in motor vehicle collisions. The Neck Disability Index (NDI) [1] is designed to measure neck-specific disability. The questionnaire has 10 items concerning pain and activities of daily living including personal care, lifting, reading, headaches, concentration, work status, driving, sleeping and recreation.

This form has been designed to give your health practitioner information as to how your neck pain has affected your ability to manage in everyday life.

Please answer every applicable section and select a response which applies to you.

We realise you may consider that two of the statements in any one section relate to you, but please select the box which most closely describes your problem.

Your details
Name *
Name
Your main daytime contact number
Questions
Pain Intensity *
Personal care *
Lifting *
Reading *
Headaches *
Concentration *
Work *
Driving *
Sleeping *
Recreation *
Thank you!
Submitting this form will form a valuable part of our ongoing assessment of your functional capacity, your treatment and your recovery.

To discuss further or learn more about our clinic and treatment options please don’t hesitate to get in touch with us by clicking here.

Or, call us on (02) 9665 9667 during business hours.