NICHQ Vanderbilt Assessment Follow-up—PARENT Informant

REIS Pediatrics

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 in the past _____________ 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, for example, 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 - 0 Occasionally - 1 Often - 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 Problematic - 4 Problematic - 5

21. Writing

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

22. Mathematics

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

23. Relationship with parents

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

24. Relationship with siblings

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

25. Relationship with peers

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

26. Participation in organized activities (eg, teams

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

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:

For Offices Only

Total Symptom Score for questions 1–18

Average Performance Score for questions 19–26:

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