NICHQ Vanderbilt Assessment Follow-up-PARENT Informant

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Child's Name(Required)
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Parent's Name(Required)
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...(Required)
NeverOccasionallyOftenVery Often
Does not pay attention to details or makes careless mistakes with, for example, homework
Has difficulty keeping attention to what needs to be done
Does not seem to listen when spoken to directly
Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
Has difficulty organizing tasks and activities
Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
Is easily distracted by noises or other stimuli
Is forgetful in daily activities
Fidgets with hands or feet or squirms in seat
Leaves seat when remaining seated is expected
Runs about or climbs too much when remaining seated is expected
Has difficulty playing or beginning quiet play activities
Is "on the go" or often acts as if "driven by a motor"
Talks too much
Blurts out answers before questions have been completed
Has difficulty waiting his or her turn
Interrupts or intrudes in on others' conversations and/or activities
ExcellentAbove AverageAverageSomewhat of a ProblemProblematic
Overall school performance
Reading
Writing
Mathematics
Relationship with parents
Relationship with siblings
Relationship with peers
Participation in organized activities (eg, teams)
NoneMildModerateSevere
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Socially withdrawn - decreased interaction with others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