Vanderbilt ADHD Diagnostic Form

Teacher's Name

Class Time:

Class Name/Period:

Today's Date:

Child's Name:

Grade Level:

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year.

Please indicate the number of weeks or months you have been able to evaluate the behaviors:

Is this evaluation based on a time when the child

was on medication was not on medication not sure?

Symptoms

0 - Never 1 - Occasionally 2 - Often 3 - Very Often

1. Fails to give attention to details or makes careless mistakes in schoolwork

0 1 2 3

2. Has difficulty sustaining attention to tasks or activities

0 1 2 3

3. Does not seem to listen when spoken to directly

0 1 2 3

4. Does not follow through on instruction and fails to finish schoolwork (not due to oppositional behavior or failure to understand)

0 1 2 3

5. Has difficulty organizing tasks and activities

0 1 2 3

6. Avoids, dislikes, or is reluctant to engage in tasks that require sustaining mental effort

0 1 2 3

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

0 1 2 3

8. Is easily distracted by extraneous stimuli

0 1 2 3

9. Is forgetful in daily activities

0 1 2 3

10. Fidgets with hands or feet or squirms in seat

0 1 2 3

11. Leaves seat in classroom or in other situations in which remaining seated is expected

0 1 2 3

12. Runs about or climbs excessively in situations in which remaining seated is expected

0 1 2 3

13. Has difficulty playing or engaging in leisure activities quietly

0 1 2 3

14. Is “on the go” or often acts as if “driven by a motor”

0 1 2 3

15. Talks excessively

0 1 2 3

16. Blurts out answers before questions have been completed

0 1 2 3

17. Has difficulty waiting in line

0 1 2 3

18. Interrupts or intrudes on others (e.g., butts into conversations or games)

0 1 2 3

19. Loses temper

0 1 2 3

20. Actively defies or refuses to comply with adults’ requests or rules

0 1 2 3

21. Is angry or resentful

0 1 2 3

22. Is spiteful and vindictive

0 1 2 3

23. Bullies, threatens, or intimidates others

0 1 2 3

24. Initiates physical fights

0 1 2 3

25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others)

0 1 2 3

26. Is physically cruel to people

0 1 2 3

27. Has stolen items of nontrivial value

0 1 2 3

28. Deliberately destroys others’ property

0 1 2 3

29. Is fearful, anxious, or worried

0 1 2 3

30. Is self-conscious or easily embarrassed

0 1 2 3

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

0 1 2 3

32. Feels worthless or inferior

0 1 2 3

33. Blames self for problems, feels guilty

0 1 2 3

34. Feels lonely, unwanted, or unloved; complains that “no one loves him/her”

0 1 2 3

35. Is sad, unhappy, or depressed

0 1 2 3

Performance

Academic Performance

1 - Excellent 2 - Above Average 3 - Average 4 - Somewhat of a Problem 5 - Problematic

36. Reading

1 2 3 4 5

37. Mathematics

1 2 3 4 5

38. Written expression

1 2 3 4 5

Classroom Behavioral Performance

1 - Excellent 2 - Above Average 3 - Average 4 - Somewhat of a Problem 5 - Problematic

39. Relationships with peers

1 2 3 4 5

40. Following directions/rules

1 2 3 4 5

41. Disrupting class

1 2 3 4 5

42. Assignment completion

1 2 3 4 5

43. Organizational skills

1 2 3 4 5

Comments:

Please return this form to:

Mailing Address:

City:

State:

Zip:

Fax:

For Office Use Only

Total number of questions scored 2 or 3 in questions 1–9:

Total number of questions scored 2 or 3 in questions 10–18:

Total Symptom Score for questions 1–18:

Total number of questions scored 2 or 3 in questions 19–28:

Total number of questions scored 2 or 3 in questions 29–35:

Total number of questions scored 4 or 5 in questions 36–43:

Average Performance Score:

Your information will be encrypted.

Vanderbilt ADHD Diagnostic Form - Teacher Informant

Symptoms

Performance

Academic Performance

Classroom Behavioral Performance

For Office Use Only