ADHD Vanberbilt Assessment Follow up - TEACHER Informant

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 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

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

5. Has difficulty organizing tasks and activities.

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

8. Is easily distracted by noises or other stimuli.

Never [0] Occasionally [1] Often [2] Very Often [3]

9. Is forgetful in daily activities.

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

11. Leaves seat when remaining seated is expected.

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

13. Has difficulty playing or beginning quiet play activities .

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never [0] Occasionally [1] Often [2] Very Often [3]

15. Talks too much.

Never [0] Occasionally [1] Often [2] Very Often [3]

16. Blurts out answers before questions have been completed.

Never [0] Occasionally [1] Often [2] Very Often [3]

17. Has difficulty waiting his or her turn.

Never [0] Occasionally [1] Often [2] Very Often [3]

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

Never Occasionally Often Very Often

Performance

Side Effects: Has your child experienced any of the following side Are these side effects currently a problem? effects or problems in the past week?

Explain/Comments

For Office Use Only

Total Symptom Score for questions 1–18

Average Performance Score for questions 19–26

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