NICHQ Vanderbilt Assessment Scale Follow-up - PARENT Informant

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This evaluation based on a time when the child:

was on medication

was not on medication

not sure

This evaluation based on a time when the child:*

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/her 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 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/her turn.*

Never

Occasionally

Often

Very Often

18. Interrupts or bothers others when they are talking or during activities.*

Never

Occasionally

Often

Very Often

19. Overall school performance*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

20. Reading*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

21. Writing*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

22. Mathematics*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

23. Relationship with parents*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

24. Relationship with siblings*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

25. Relationship with peers*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

26. Participation in organized activities (eg,teams)*

Excellent

Above Average

Average

Somewhat of a Problem

Problematic

Side Effects: Has your child experienced headache in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced stomachache in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced change in appetite in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced trouble sleeping in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced irritability in the late morning, late afternoon, or evening in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child been socially withdrawn (decreased interaction with others) in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced extreme sadness or unusual crying in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced dull, tired, listless behavior in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced tremors/feeling shaky in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced repetitive movements, tics, jerking, twitching, eye blinking in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child experienced picking at skin or fingers, nail biting, lip or cheek chewing in the past week?*

None

Mild

Moderate

Severe

Side Effects: Has your child seen or heard things that aren’t there in the past week?*

None

Mild

Moderate

Severe

Patient's Name*

Date of Birth*

Form Completed By*

Relationship To Patient*

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Predominantly Inattentive Subtype Score

Any score 6 or greater.

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Predominantly Hyperactive/Impulsive Subtype Score

Any score 6 or greater.

VANDERBILT ASSESSMENT