Vanderbilt Parent Assessment

Today's Date:

Child's Name:

DOB:

Parent's Names:

Each rating should be considered in the context of what is appropriate for the age of your child.

Is this evaluation based on a time when the child

was on medication was not on medication

SYMPTOMS

1. Does not pay attention to details or makes careless mistakes with, for example, homework

Never

Occasionally

Often

Very Often

2. Has difficulty keeping attention to what needs to be done

Never

Occasionally

Often

Very Often

3. Does not seem to listen when spoken to directly

Never

Occasionally

Often

Very Often

4. Does not follow through when given directions and fails to finish activities (not due to refusal or misunderstanding)

Never

Occasionally

Often

Very Often

5. Has difficulty organizing task and activities

Never

Occasionally

Often

Very Often

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental efforts

Never

Occasionally

Often

Very Often

7. Loses things necessary for tasks Or activities (toys, assignments, pencils, or books)

Never

Occasionally

Often

Very Often

8. Is easily distracted by noises or other stimuli

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat

Never

Occasionally

Often

Very Often

11. Leaves seat when remaining seated is expected

Never

Occasionally

Often

Very Often

12. Runs about or climbs too much when remaining sealed is expected

Never

Occasionally

Often

Very Often

13. Has difficulty playing or beginning quiet play activities

Never

Occasionally

Often

Very Often

14. Is "on the go" or often acts as if "driven by a motor:

Never

Occasionally

Often

Very Often

15. Talks too much

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed

Never

Occasionally

Often

Very Often

17. Has difficulty waiting his/her tum

Never

Occasionally

Often

Very Often

18. Interrupts or intrudes in others' conversations and/or activities

Never

Occasionally

Often

Very Often

19. Argues with adults

Option 1 Option 2 Option 3 Option 4

20. Loses temper

Never Occasionaly

Often

Very Often

21. Actively defies or refuses to go along with adult's requests or rules

Never Occasionally

Often

Very Often

22. Deliberatley annoys people

Never Occasionaly

Often

Very Often

23. Blames others for his or her mistakes or misbehaviors

Never Occasionaly

Often

Very Often

24. Is touchy or annoyed by others

Never Occasionaly

Often

Very Often

25. Is Angry or resentful

Never Occasionaly

Often

Very Often

26. Is spiteful and wants to get even

Never Occasionally

Often

Very Often

27. Bullies, threatens or intimidates others

Never Occasionally

Often

Very Often

28. Starts physical fights

Never Occasionaly

Often

Very Often

29. Lies to get out of trouble or to avoid obligations(ie "cons" others)

Never Occasionaly

Often

Very Often

30. Is truant form school (skips school) without permission

Never Occasionally

Often

Very Often

31. Is physically cruel to others people

Never Occasionaly

Often

Very Often

32. Has stolen things that have value

Never Occasionaly

Often

Very Often

33. Deliberately destoys other's properties

Never Occasionally

Often

Very Often

34. has used a weapon that can cause serious harm(bat, knife, brick, gun)

Never Occasionally

Often

Never

35. Is physically cruel to animals

Never Occasionally

Often

Very Often

36. Has deriberatley set fires to cause damage

Never Occasionally

Often

Very Often

37. Has broken into someone else's home, business, or car

Never Occasionally

Often

Very Often

38. Has stayed out at night without permission

Never Occasionally

Often

Very Often

39. has run away from home overnight

Never Occasionally

Often

Very Often

40. Has forced someone into sexual activity

Never Occasionaly

Often

Very Often

41. Is fearful, anxious or worried

Never Occasionaly

Often

Very Often

42. Is afraid to try new things for fear of making mistakes

Never Occasionally

Often

Very Often

43. Feels worthless or inferior

Never Occasionaly

Often

Very Often

44. Blames self for problems, feels guilty

Never Occasionaly

Often

Very Often

45. Feels lonely unwanted, or unloved; complains that 'no one loves him or her'

Never Occasionaly

Often

Very Often

46. Is sad, unhappy, or depressed

Never Occasionally

Often

Very Often

47. Is self conscious or easily embarrased

Never Occasionally

Often

Very often

Performance

48.Overall School performance

Excellent

Above Average

Average

Somewhat of a problem

Promlematic

49. Reading

Excellent

Above average

Average

Somewhat of a Problem

Problematic

50. Writing

Excellent

Above average

Average

Somewhat of a Problem

Problematic

51. Mathematics

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

52, Relationship with parents

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

53. Relationship with Siblings

Excellent

Above Average

Average

Somewhat of a problm

Problematic

54. Relationship with peers

Excellent

Above Average

Average

Somewhat of a Porblem

Problematic

55. Participation in organized Activities (eg, teams)

Excellent

Above Average

Average

Somewha of a Problem

Problematic

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