PARENT FOLLOW UP ADHD Questionnaire (Vanderbilt)

Today's Date

Child's Full Name

Child's Date of Birth

Parent's Full Name

Parent's Phone Number

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child’s behaviors in the past 6 months.

Is this evaluation based on a time when the child:

was on medication? was NOT on medication?

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

Overall school performance

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Reading

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Writing

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Mathematics

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Relationship with parents

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Relationship with siblings

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Relationship with peers

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Participation in organized activities

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

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 --- explain below

None Mild Moderate Severe

Trouble sleeping

None Mild Moderate Severe

Irritability in the late morning, late afternoon, or evening --- explain below

None Mild Moderate Severe

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 --- explain below

None Mild Moderate Severe

Picking at skin or fingers, nail biting, lip or cheek chewing --- explain below

None Mild Moderate Severe

Sees or hears things that aren't there

None Mild Moderate Severe

Explain/Comments

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