NICHQ Vanderbilt Assessment Follow-up

Today's Date:

Child’s Name:

Date of Birth:

Parent's Name:

Parent's Phone Number:

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 last assessment scale was filled out.

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

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 failure to understand)

Never Occasionally

Often

Very Often

5. Has difficulty organizing tasks and activities

Never Occasionally

Often

Very Often

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

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 seated 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 or her turn

Never Occasionally

Often

Very Often

18. Interrupts or intrudes in on others’ conversations and/or activities

Never Occasionally

Often

Very Often