Vanderbilt Teacher ADHD Assessment | Pediatric Associates

Vanderbilt Assessment - Teacher Informant

Child's Name *

First name

Last name

Child's Date of Birth

Month

Day

Year

Child's Provider

Completed by *

First Name

Last Name

Class/Subject

Date of Appointment

Each rating should be considered in the context of what is appropriate for the age of the child.

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

Never

Occasionally

Often

Very Often

2. Has difficulty keeping attention to what needs to be done

Never

Occasionally

Often

Very Often

3. Does not seem to listen when spoken to directly

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

5. Has difficulty organizing tasks and activities

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

7. Loses things necessary for task or activities (toys, assignments, pencils, or books)

Never

Occasionally

Often

Very Often

8. Is easily distracted by noises or other stimuli

Never

Occasionally

Often

Very Often

9. Is forgetful in daily activities

Never

Occasionally

Often

Very Often

10. Fidgets with hands or feet or squirms in seat

Never

Occasionally

Often

Very Often

11. Leaves eat when remaining seated is expected

Never

Occasionally

Often

Very Often

12. Runs about or climbs too much when remaining seated is expected

Never

Occasionally

Often

Very Often

13. Has difficulty playing or beginning quiet play activities

Never

Occasionally

Often

Very Often

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

Never

Occasionally

Often

Very Often

15. Talks too much

Never

Occasionally

Often

Very Often

16. Blurts out answers before questions have been completed

Never

Occasionally

Often

Very Often

17. Has difficulty waiting his/her turn

Never

Occasionally

Often

Very Often

18. Interrupts or intrudes in on others' conversations and/or activities

Never

Occasionally

Often

Very Often

Performance

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

Headache

None

Mild

Moderate

Severe

Stomachache

None

Mild

Moderate

Severe

Change of appetite - explain below

None

Mild

Moderate

Severe

Trouble sleeping

None

Mild

Moderate

Severe

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

None

Mild

Moderate

Severe

Socially withdrawn/decreased interaction with others

None

Mild

Moderate

Severe

Extreme sadness or unusual crying

None

Mild

Moderate

Severe

Dull, tired, listless behavior

None

Mild

Moderate

Severe

Tremors/feeling shaky

None

Mild

Moderate

Severe

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

None

Mild

Moderate

Severe

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

None

Mild

Moderate

Severe

Sees or hears things that aren't there

None

Mild

Moderate

Severe

Explain/Comments

I understand that the information submitted may include personal health information and consent to its secure storage and use.

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Vanderbilt Assessment - Teacher Informant