NECK DISABILITY INDEX RESULT

Date: [Date]
Patient: [Name or ID, age]
Visit: [Initial exam, re-exam, progress visit, or discharge]
How completed: [Official NDI form on paper or tablet; by the patient or read to them word for word; language version]

NECK PROBLEM
Presenting complaint: [Neck pain, with or without arm symptoms or headaches]
Onset: [Date, and how it started: gradually, an injury, a collision, or after surgery]
Working diagnosis: [Mechanical neck pain, whiplash-associated disorder, cervical radiculopathy, or other]

NDI TODAY
Sections answered: [Number out of 10; any left blank, and why]
Raw score: [Total out of 50]
Percent: [Raw score doubled, or prorated for blank sections]
Disability level: [None, mild, moderate, severe, or complete]
Sections of note: [Sections scoring 3 or more, such as headaches, sleeping, or driving]

COMPARED WITH BASELINE
Baseline NDI: [Date, raw score, and percent]
Scores since: [Dates and raw scores]
Change: [Points down or up, and whether it passes the change your clinic counts as meaningful]

FINDINGS ALONGSIDE
Pain rating: [0 to 10, now and at worst]
Exam: [Cervical range of motion, neurological screen of the arms, and other key findings]
Barriers to recovery: [Sleep, mood, fear of movement, work demands, or none found]

PLAN
Treatment: [Exercise, manual therapy, education, home program, or medicine review]
Referral: [To whom, why, and how soon, or none]
Work and driving: [Full duties, modified duties, time off, and any limits]
Next NDI: [Date or visit number]

Clinician: [Name, credentials]