NICHQ Vanderbilt Assessment Follow-up—PARENT Informant
Sign in to Google to save your progress. Learn more
Today's Date: *
MM
/
DD
/
YYYY
Patient's Name: *
Patient's Date Of Birth: *
MM
/
DD
/
YYYY
Parent's/Guardian's Name: *
Parent's/Guardian's Phone Number: *
Is this evaluation based on a time when the child *
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 since the last assessment scale was filled out when rating his/her behaviors.  
 *
0- Never
1- Occasionally
2- Often
3- Very Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
*
0- Never
1- Occasionally
2- Often
3- Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others’ conversations and/or activities
Performance  
 *
1- Excellent
2- Above Average
3- Average
4- Somewhat of a Problem
5- Problematic
19. Overall school performance
20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings
25. Relationship with peers
26. Participation in organized activities (eg, teams)
Side Effects:

Has your child experienced any of the following side effects or problems in the past week?

Are these side effects currently a problem?  
 *
None
Mild
Moderate
Severe
Headache
Stomachache
Change of appetite—explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening—explain below
Socially withdrawn—decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Sees or hears things that aren’t there
 Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality
 Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. 
Revised - 0303  
 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms