Parent Vanderbilt Follow-up Questionnaire

NICHQ Vanderbilt Assessment Follow-up - PARENT Informant

Today's Date

Child's Full Name

Child's Date of Birth

Parent's Name

Parent's Phone Number

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 behaviours since the last assessment scale was filled out when rating their behaviours.

Is this evaluation based on a time when the child *

was on medicationwas not on medicationnot sure?

Symptoms *

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not pay attention to details or makes careless mistakes with, for example, homework

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty keeping attention to what needs to be done

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not seem to listen when spoken to directly

Never (0)Occasionally (1)Often (2)Very Often (3)

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty organising tasks and activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

Never (0)Occasionally (1)Often (2)Very Often (3)

Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

Never (0)Occasionally (1)Often (2)Very Often (3)

Is easily distracted by noises or other stimuli

Never (0)Occasionally (1)Often (2)Very Often (3)

Is forgetful in daily activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Fidgets with hands or feet or squirms in seat

Never (0)Occasionally (1)Often (2)Very Often (3)

Leaves seat when remaining seated is expected

Never (0)Occasionally (1)Often (2)Very Often (3)

Runs about or climbs too much when remaining seated is expected

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty playing or beginning quiet play activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Is "on the go" or often acts as if "driven by a motor"

Never (0)Occasionally (1)Often (2)Very Often (3)

Talks too much

Never (0)Occasionally (1)Often (2)Very Often (3)

Blurts out answers before questions have been completed

Never (0)Occasionally (1)Often (2)Very Often (3)

Has difficulty waiting his or her turn

Never (0)Occasionally (1)Often (2)Very Often (3)

Interrupts of intrudes in on others' conversations and/or activities

Never (0)Occasionally (1)Often (2)Very Often (3)

Performance *

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Overall school performance

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Reading

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Writing

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Mathematics

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with parents

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with siblings

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Relationship with peers

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

Participation in organised activities (e.g., teams)

Excellent (1)Above Average (2)Average (3)Somewhat of a Problem (4)Problematic (5)

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

NoneMildModerateSevere

Headache

NoneMildModerateSevere

Stomachache

NoneMildModerateSevere

Change of appetite - explain below

NoneMildModerateSevere

Trouble sleeping

NoneMildModerateSevere

Irritability in the late morning, late afternoon, or evening - explain below

NoneMildModerateSevere

Socially withdrawn - decreased interaction with others

NoneMildModerateSevere

Extreme sadness or unusual crying

NoneMildModerateSevere

Dull, tired, listless behaviour

NoneMildModerateSevere

Tremors/feeling shaky

NoneMildModerateSevere

Repetitive movements, tics, jerking, twitching, eye blinking - explain below

NoneMildModerateSevere

Picking at skin or fingers, nail biting, lip or cheek chewing - explain below

NoneMildModerateSevere

Sees or hears things that aren't here

NoneMildModerateSevere

Explain/Comments

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