Vanderbilt Parent ADHD Assessment | Pediatric Associates

Vanderbilt Assessment - Parent Informant

Child's Name *

First name

Last name

Child's Date of Birth

Month

Day

Year

Parent's Name *

First Name

Last Name

Child's Provider

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, such as in home-work

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 tasks 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 seat 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

19. Argues with adults

Never

Occasionally

Often

Very Often

20. Loses temper

Never

Occasionally

Often

Very Often

21. Actively defies or refuses to go along with adults' request/rules

Never

Occasionally

Often

Very Often

22. Deliberately annoys people

Never

Occasionally

Often

Very Often

23. Blames others for his/her mistakes or misbehavior

Never

Occasionally

Often

Very Often

24. Is touchy or easily annoyed by others

Never

Occasionally

Often

Very Often

25. Is angry or resentful

Never

Occasionally

Often

Very Often

26. Is spiteful and wants to get even

Never

Occasionally

Often

Very Often

27. Bullies, threatens, or intimidates others

Never

Occasionally

Often

Very Often

28. Starts physical fights

Never

Occasionally

Often

Very Often

29. Lies to get out of trouble or to avoid obligations (ie, "cons" others)

Never

Occasionally

Often

Very Often

30. Is traunt from school (skips school) without permission

Never

Occasionally

Often

Very Often

31. Is physically cruel to people

Never

Occasionally

Often

Very Often

32. Has stolen things that have value

Never

Occasionally

Often

Very Often

33. Deliberately destroys others' property

Never

Occasionally

Often

Very Often

34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)

Never

Occasionally

Often

Very Often

35. Is physically cruel to animals

Never

Occasionally

Often

Very Often

36. Has deliberately set fires to cause damage

Never

Occasionally

Often

Very Often

37. Has broken into someone else's home, business, or car

Never

Occasionally

Often

Very Often

38. Has stayed out at night without permission

Never

Occasionally

Often

Very Often

39. Has run away from home overnight

Never

Occasionally

Often

Very Often

40. Has forced someone into sexual activity

Never

Occasionally

Often

Very Often

41. Is fearful, anxious, or worried

Never

Occasionally

Often

Very Often

42. Is afraid to try new things for fear of making mistakes

Never

Occasionally

Often

Very Often

43. Blames self for problems, feels guilty

Never

Occasionally

Often

Very Often

44. Feels worthless or inferior

Never

Occasionally

Often

Very Often

45. Feels lonely, unwanted, or unloved; complains that "no one loves him/her"

Never

Occasionally

Often

Very Often

46. Is sad, unhappy, or depressed

Never

Occasionally

Often

Very Often

47. Is self-conscious or easily embarassed

Never

Occasionally

Often

Very Often

Performance

Additional Comments

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

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781-769-4090 or 508-528-5404

Vanderbilt Assessment - Parent Informant