NICHQ Vanderbilt Assessment Follow-Up (Parent Informant)

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 your 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 no on medication

not sure?

Symptoms

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

Never Occasionally [ 1 ] Often [ 2 ] Very Often [ 3 ]

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

Never Occasionally [ 1 ] Often [ 2 ] Very Often [ 3 ]

3. Does not seem to listen when spoken to directly.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

4. Does not allow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

5. Has difficulty organizing tasks and activities.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

6. Avoid, dislikes, or does not want to start task that require ongoing mental effort.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

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

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

8. Is easily distracted by noises or other stimuli.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

9. Is forget in daily activities.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

10. Fidgets with hands or feet or squirms in seat.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

11. Leaves seat when remaining seated is expected.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

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

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

13. Has difficulty playing or beginning quit play activities.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

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

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

15. Talks too much.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

16. Blurts out answers before questions have been completed.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

17. Has difficulty waiting his or her turn.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

18. Interrupts or intrudes in on other's conversations and/or activities.

Never Occasionally [ 1 ] Ofter [ 2 ] Very Often [ 3 ]

Performance

19. Overall school performance.

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

20. Reading.

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

21. Writing

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

22. Mathematics

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

23. Relationship with parents.

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

24. Relationship with siblings

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

25. Relationship with peers.

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

26. Participation in organized activities (eg, teams)

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

The information contained in this publication should not be used as a substitute for the medical care and advice your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children's Healthcare Quality.
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, M.D. Revised - 0303

Side Effects:

Are these side effects currently a problem?

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

Headache

None Mild Moderate Severe

Stomachache

None Mild Moderate Severe

Change of appetite (Explain Below)

None Mild Moderate Severe

Explaination:

Trouble sleeping

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening (Explain Below)

None Mild Moderate Severe

Explaination:

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