NICHQ Vanderbilt ADHD Assessment Follow Up - Parent Informant

Today's Date*

Date

Child's Name*

First NameLast Name

Child's Date of Birth*

Date

Parent's Name*

First NameLast Name

Parent's Phone Number*

Area CodePhone Number

Parent's Email*

example@example.com

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.

Is this evaluation based on a time when the child*

was on medicationwas not on medicationnot sure

Symptoms

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*

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-	2-	3-	4-	5-
	Excellent	Above Average	Average	Somewhat of a Problem	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

Are these side effects currently a problem?

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

0-None

1-Mild

2-Moderate

3-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*

Explain/Comments:

**The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.