Vanderbilt Assessment Form

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 not on medication not sure?

Symptoms

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

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

0 1 2 3

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

0 1 2 3

3. Does not seem to listen when spoken to directly

0 1 2 3

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

0 1 2 3

5. Has difficulty organizing tasks and activities

0 1 2 3

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

0 1 2 3

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

0 1 2 3

8. Is easily distracted by noises or other 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 when remaining seated is expected

0 1 2 3

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

0 1 2 3

13. Has difficulty playing or beginning quiet play activities

0 1 2 3

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

0 1 2 3

15. Talks too much

0 1 2 3

16. Blurts out answers before questions have been completed

0 1 2 3

17. Has difficulty waiting his or her turn

0 1 2 3

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

0 1 2 3

Performance

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

19. Overall school performance

1 2 3 4 5

20. Reading

1 2 3 4 5

21. Writing

1 2 3 4 5

22. Mathematics

1 2 3 4 5

23. Relationship with parents

1 2 3 4 5

24. Relationship with siblings

1 2 3 4 5

25. Relationship with peers

1 2 3 4 5

26. Participation in organized activities (eg, teams)

1 2 3 4 5

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

Side Effects:

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

None Mild Moderate Severe

Please explain:

Trouble sleeping

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening

None Mild Moderate Severe

Please explain:

Socially withdrawn—decreased interaction with others

None Mild Moderate Severe

Extreme sadness or unusual crying

None Mild Moderate Severe

Dull, tired, listless behavior

None Mild Moderate Severe

Tremors/feeling shaky

None Mild Moderate Severe

Repetitive movements, tics, jerking, twitching, eye blinking

None Mild Moderate Severe

Please explain:

Picking at skin or fingers, nail biting, lip or cheek chewing

None Mild Moderate Severe

Sees or hears things that aren’t there

None Mild Moderate Severe

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