NICHQ Vanderbilt Assessment Scale—PARENT Informant

Today's Date:

Child's Name:

Date of Birth:

Parent's Name:

Parent's Phone Number:

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

Symptoms

Performance

Comments:

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Total number of questions scored 2 or 3 in questions 1–9:

Total number of questions scored 2 or 3 in questions 10–18:

Total Symptom Score for questions 1–18:

Total number of questions scored 2 or 3 in questions 19–26:

Total number of questions scored 2 or 3 in questions 27–40:

Total number of questions scored 2 or 3 in questions 41–47:

Total number of questions scored 4 or 5 in questions 48–55:

Average Performance Score:

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