NICHQ Vanderbilt Assessment Follow up —PARENT Informant

NICHQ Vanderbilt Assessment Follow up — PARENT Informant

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 his/her behaviours.

Step 1 of 4

Today's Date
Date Format: MM slash DD slash YYYY
Child’s Name:*
First Last
Date Of Birth:*
Date Format: DD slash MM slash YYYY
Parents Name:*
First Last
Parents Phone Number:*
Is this evaluation based on a time when the child*
- was on medication
- was not on medication
- not sure?

Symptoms
1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is “on the go” or often acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others’ conversations and/or activities

Performance
19. Overall school performance
20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings
25. Relationship with peers
26. Participation in organized activities (eg, teams)

Side Effects:
Has your child experienced any of the following side effects or problems in the past week?
Headache
Is this side effects currently a problem?
Stomachache
Is this side effects currently a problem?
Change of appetite—explain below
Is this side effects currently a problem?
Trouble sleeping
Is this side effects currently a problem?
Irritability in the late morning, late afternoon, or evening—explain below
Is this side effects currently a problem?
Socially withdrawn—decreased interaction with others
Is this side effects currently a problem?
Extreme sadness or unusual crying
Is this side effects currently a problem?
Dull, tired, listless behavior
Is this side effects currently a problem?
Tremors/feeling shaky
Is this side effects currently a problem?
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Is this side effects currently a problem?
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Is this side effects currently a problem?
Sees or hears things that aren’t there
Is this side effects currently a problem?
Explain/Comments:
Comments:

NICHQ Vanderbilt Assessment Follow up — PARENT Informant

Step 1 of 4

Symptoms

Performance

Side Effects:

Explain/Comments:

Campbelltown Centre:

Oran Park Centre:

Campbelltown Centre:

Oran Park Centre: