Name: Pediatric People
Price range: $

This evaluation based on a time when the child:

was on medication

was not on medication

not sure

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(Required)

First Last

Date of Birth(Required)

Form Completed By(Required)

First Last

Relationship To Patient(Required)

Mother

Father

Other

Hidden

Predominantly Inattentive Subtype Score

Any score 6 or greater.

Hidden

Predominantly Hyperactive/Impulsive Subtype Score

Any score 6 or greater.

VANDERBILT ASSESSMENT