Independence & Lee’s Summit Pediatrics

NICHQ Vanderbilt Assessment Follow-up
PARENT Informant

Patient name  
Parent’s name  
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  
Symptoms
   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, school 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 awaiting his or her turn  
   18. Interrupts or intrudes in on others’ conversations and/or activities  
Performance
   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)  
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
Side Effects
Has your child experienced any of the following side effects or problems in the past week?
   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   Socially withdrawn — decreased interaction with others 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  
Adapted from the Pittsburgh side effects scale, developed by William E. Pelham, Jr, PhD.
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