NICHQ Vanderbilt Assessment Follow up — PARENT Informant

Step 1 of 3

Basic Information

Is this evaluation based on a time when the child(Required)

was on medication

was not on medication

not sure

Today's Date(Required)

Child's Name(Required)

First Name Last Name

Date of birth(Required)

Parent's Name(Required)

First Name Last Name

Parent's Phone Number(Required)

Symptoms

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

2. Has difficulty keeping attention to what needs to be done(Required)

3. Does not seem to listen when spoken to directly(Required)

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

5. Has difficulty organizing tasks and activities(Required)

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

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

8. Is easily distracted by noises or other stimuli(Required)

9. Is forgetful in daily activities(Required)

10. Fidgets with hands or feet or squirms in seat(Required)

11. Leaves seat when remaining seated is expected(Required)

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

13. Has difficulty playing or beginning quiet play activities(Required)

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

15. Talks too much(Required)

16. Blurts out answers before questions have been completed(Required)

17. Has difficulty waiting his or her turn(Required)

18. Interrupts or intrudes in on others’ conversations and/or activities(Required)

Kids Health Space