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NICHQ Vanderbilt Assessment Scale – PARENT Informant
Michael
2024-02-21T10:09:33-06:00
NICHQ VANDERBILT ASSESSMENT SCALE
PARENT INFORMANT
"
*
" indicates required fields
PATIENT INFORMATION
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Authorization
Patient
*
First
Last
Date of Birth
*
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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Date
*
Parent or Legal Guardian
*
First
Last
Relationship To Patient
*
Select One
Mother
Father
Other
This evaluation based on a time when the child
*
Select One
was on medication
was not on medication
not sure
SYMPTOM ASSESSMENT
Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please rate what your child does independently, without reminders, prompting, or assistance from adults in the past 6 month. Occasionally - 1-2 days per week, Often - 3-4 days per week, Very Often - 6-7 days per week or multiple times per day.
1. Does not pay attention to details or makes careless mistakes, for example homework:
*
Never
Occasionally
Often
Very Often
2. Has difficulty attending 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 things:
*
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 needed for tasks or activities (assignments, pencils, books).
*
Never
Occasionally
Often
Very Often
8. Is easily distracted by noises or other things.
*
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 he/she is suppose to stay in his seat.
*
Never
Occasionally
Often
Very Often
12. Runs about or climbs too much when he/she is suppose to stay seated.
*
Never
Occasionally
Often
Very Often
13. Has difficulty playing or starting quiet games.
*
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/her turn.
*
Never
Occasionally
Often
Very Often
18. Interrupts or bothers others when they are talking or playing games.
*
Never
Occasionally
Often
Very Often
19. Argues with adults.
*
Never
Occasionally
Often
Very Often
20. Loses temper.
*
Never
Occasionally
Often
Very Often
21. Actively disobeys or refuses to follow an adults’ requests or rules.
*
Never
Occasionally
Often
Very Often
22. Bothers people on purpose.
*
Never
Occasionally
Often
Very Often
23. Blames others for his/her mistakes or misbehaviors.
*
Never
Occasionally
Often
Very Often
24. Is touchy or easily annoyed by others.
*
Never
Occasionally
Often
Very Often
25. Is angry or bitter.
*
Never
Occasionally
Often
Very Often
26. Is hateful and wants to get even.
*
Never
Occasionally
Often
Very Often
27. Bullies, threatens, or scares others.
*
Never
Occasionally
Often
Very Often
28. Starts physical fights.
*
Never
Occasionally
Often
Very Often
29. Lies to get out of trouble or to avoid jobs (i.e., “cons” others).
*
Never
Occasionally
Often
Very Often
30. Skips school without permission.
*
Never
Occasionally
Often
Very Often
31. Is physically unkind to people.
*
Never
Occasionally
Often
Very Often
32. Has stolen things that have value.
*
Never
Occasionally
Often
Very Often
33. Destroys others’ property on purpose.
*
Never
Occasionally
Often
Very Often
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun).
*
Never
Occasionally
Often
Very Often
35. Is physically mean to animals.
*
Never
Occasionally
Often
Very Often
36. Has set fires on purpose to cause damage.
*
Never
Occasionally
Often
Very Often
37. Has broken into someone else’s home, business, or car.
*
Never
Occasionally
Often
Very Often
38. Has stayed out at night without permission.
*
Never
Occasionally
Often
Very Often
39. Has run away from home overnight.
*
Never
Occasionally
Often
Very Often
40. Has forced someone into sexual activity.
*
Never
Occasionally
Often
Very Often
41. Is fearful, nervous, or worried.
*
Never
Occasionally
Often
Very Often
42. Is afraid to try new things for fear of making mistakes.
*
Never
Occasionally
Often
Very Often
43. Feels useless or inferior.
*
Never
Occasionally
Often
Very Often
44. Blames self for problems, feels at fault.
*
Never
Occasionally
Often
Very Often
45. Feels lonely, unwanted, or unloved; complains that “no one loves him/her."
*
Never
Occasionally
Often
Very Often
46. Is sad or unhappy.
*
Never
Occasionally
Often
Very Often
47. Feels different and easily embarrassed.
*
Never
Occasionally
Often
Very Often
PERFORMANCE
48. Overall school performance
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
49. Reading
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
50. Writing
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
51. Mathematics
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
52. Relationship with parents
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
53. Relationship with siblings
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
54. Relationship with peers
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
55. Participation in organized activities (eg, teams)
*
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
Comments
SCORES
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Total number of questions scored 2 or 3 in questions 1–9:
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Total number of questions scored 2 or 3 in questions 10–18:
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Total Symptom Score for questions 1–18:
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Total number of questions scored 2 or 3 in questions 19–26:
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Total number of questions scored 2 or 3 in questions 27–40:
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Total number of questions scored 2 or 3 in questions 41–47:
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Average Performance Score:
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F124 Tie
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F126 Tie
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F128 Tie
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F130 Tie
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F133 Tie
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F134 Tie
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F136 Tie
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F138 Tie
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Total number of questions scored 4 or 5 in questions 48–55:
PREDOMINANTLY INATTENTIVE SUBTYPE:
✓ CRITERIA NOT MET
PREDOMINANTLY INATTENTIVE SUBTYPE:
⚠ CRITERIA MET
PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
✓ CRITERIA NOT MET
PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE:
⚠ CRITERIA MET
ADHD COMBINED INATTENTION / HYPERACTIVITY:
✓ CRITERIA NOT MET
ADHD COMBINED INATTENTION / HYPERACTIVITY:
⚠ CRITERIA MET
OPPOSITIONAL-DEFIANT DISORDER SCREEN:
✓ CRITERIA NOT MET
OPPOSITIONAL-DEFIANT DISORDER SCREEN:
⚠ CRITERIA MET
CONDUCT DISORDER SCREEN:
✓ CRITERIA NOT MET
CONDUCT DISORDER SCREEN:
⚠ CRITERIA MET
ANXIETY / DEPRESSION SCREEN:
✓ CRITERIA NOT MET
ANXIETY / DEPRESSION SCREEN:
⚠ CRITERIA MET
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PREDOMINANTLY INATTENTIVE SUBTYPE SCORE
Must score a 2 or 3 on 6 out of 9 items on questions 1–9 AND Score a 4 or 5 on any of the Performance questions 48–55.
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PREDOMINANTLY HYPERACTIVE / IMPULSIVE SUBTYPE
Must score a 2 or 3 on 6 out of 9 items on questions 10–18 AND Score a 4 or 5 on any of the Performance questions 48–55.
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ADHD COMBINED INATTENTION / HYPERACTIVITY
Requires the above criteria on both inattention and hyperactivity / impulsivity.
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OPPOSITIONAL-DEFIANT DISORDER SCREEN
Must score a 2 or 3 on 4 out of 8 behaviors on questions 19–26 AND Score a 4 or 5 on any of the Performance questions 48–55.
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CONDUCT DISORDER SCREEN
Must score a 2 or 3 on 3 out of 14 behaviors on questions 27–40 AND Score a 4 or 5 on any of the Performance questions 48–55.
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ANXIETY / DEPRESSION SCREEN
Must score a 2 or 3 on 3 out of 7 items on questions 41–47 AND Score a 4 or 5 on any of the Performance questions 48–55.
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