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. Please think about your child's behaviors since the last assessment scale was filled out when rating his/her 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

Performance

19. Overall school performance:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

20. Reading:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

21. Writing:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

22. Mathematics

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

23. Relationship with parents:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

24. Relationship with siblings:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

25. Relationship with peers:

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

26. Participation in organized activities (eg, teams):

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Side Effects:

Has the child experienced any of the following side effects or problems in the past week?

Headache: Are these side effects currently a problem?

None Mild Moderate Severe

Stomachache: Are these side effects currently a problem?

None Mild Moderate Severe

Change of appetite-explain below: Are these side effects currently a problem?

None Mild Moderate Severe

Trouble sleeping: Are these side effects currently a problem?

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening-explain below: Are these side effects currently a problem?

None Mild Moderate Severe

Socially withdrawn-decreased interaction with others Are these side effects currently a problem?

None Mild Moderate Severe

Extreme sadness or unusual crying: Are these side effects currently a problem?

None Mild Moderate Severe

Dull, tired, listless behavior: Are these side effects currently a problem?

None Mild Moderate Severe

Tremors/feeling shaky: Are these side effects currently a problem?

None Mild Moderate Severe

Repetitive movements, tics, jerking, twitching, eye blinking- explain below: Are these side effects currently a problem?

None Mild Moderate Severe

Picking at skin or fingers, nail biting, lip or cheek chewing-explain below: Are these side effects currently a problem?

None Mild Moderate Severe

Sees or hears things that aren't there: Are these side effects currently a problem?

None Mild Moderate Severe

Explain/Comments:

Your information will be encrypted.

NICHQ Vanderbilt Assessment Follow-up - PARENT Informant

Symptoms

Performance

Side Effects: