NICHQ Vanderbilt Assessment

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NICHQ Vanderbilt Assessment Follow-up

Parent Informant Form

Basic Information

Today's Date *

Child's Name *

Date of Birth *

Parent's Name *

Parent's Phone Number

Is this evaluation based on a time when the child:

Was on medication Was not on medication Not sure

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.

Symptoms Assessment

Symptoms	Never (0)	Occasionally (1)	Often (2)	Very Often (3)
1Does not pay attention to details or makes careless mistakes with, for example, homework
2Has difficulty keeping attention to what needs to be done
3Does not seem to listen when spoken to directly
4Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5Has difficulty organizing tasks and activities
6Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8Is easily distracted by noises or other stimuli
9Is forgetful in daily activities
10Fidgets with hands or feet or squirms in seat
11Leaves seat when remaining seated is expected
12Runs about or climbs too much when remaining seated is expected
13Has difficulty playing or beginning quiet play activities
14Is "on the go" or often acts as if "driven by a motor"
15Talks too much
16Blurts out answers before questions have been completed
17Has difficulty waiting his or her turn
18Interrupts or intrudes in on others' conversations and/or activities

Performance

Performance	Excellent (1)	Above Average (2)	Average (3)	Somewhat of a Problem (4)	Problematic (5)
19Overall school performance
20Reading
21Writing
22Mathematics
23Relationship with parents
24Relationship with siblings
25Relationship with peers
26Participation in organized activities (eg, teams)

Side Effects (Past Week)

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

Side Effect	None	Mild	Moderate	Severe
Headache
Stomachache
Change of appetite
Trouble sleeping
Irritability in the late morning, late afternoon, or evening
Socially withdrawn - decreased interaction with others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
Picking at skin or fingers, nail biting, lip or cheek chewing
Sees or hears things that aren't there

Comments

Additional comments or explanations:

0 / 2500 characters

Send Results To (Email) *

Assessment Submitted Successfully!

Thank you for completing the Vanderbilt Assessment.

Results sent to: -

Summary Scores

Total Symptom Score (Questions 1-18): -

Average Performance Score (Questions 19-26): -