Adolescent ADHD Parent Collateral Form
Complete this form as a parent or primary caregiver about the adolescent’s behavior over the past 6 months.
Patient and Respondent Information
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Respondent Full Name
*
Respondent Relationship to Patient
*
Please Select
Mother
Father
Guardian
Grandparent
Other
Today's Date
*
-
Month
-
Day
Year
Date
Vanderbilt Symptom Ratings
Fails to give close attention to details or makes careless mistakes
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty sustaining attention
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Does not seem to listen when spoken to directly
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Does not follow through on instructions and fails to finish tasks
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty organizing tasks and activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Loses things necessary for tasks or activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is easily distracted by extraneous stimuli
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is forgetful in daily activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Fidgets with hands or feet or squirms in seat
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Leaves seat when remaining seated is expected
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Runs about or climbs in inappropriate situations
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty playing or engaging in leisure activities quietly
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is often “on the go” or acts as if “driven by a motor”
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Talks excessively
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Blurts out answers before questions have been completed
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty waiting his or her turn
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Interrupts or intrudes on others
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Argues with adults
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Loses temper
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Actively defies or refuses to comply with adults' requests or rules
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is spiteful or vindictive
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is fearful, anxious, or worried
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Is sad, unhappy, or depressed
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Has difficulty enjoying activities
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Complains of physical symptoms without a medical cause
*
Never
0
1
2
Very Often
3
0 is Never, 3 is Very Often
Performance Ratings
Reading
*
1
2
3
4
5
Mathematics
*
1
2
3
4
5
Written expression
*
1
2
3
4
5
Relationship with parents
*
1
2
3
4
5
Relationship with siblings
*
1
2
3
4
5
Relationship with peers
*
1
2
3
4
5
Following directions
*
1
2
3
4
5
Organizational skills
*
1
2
3
4
5
Submit
Should be Empty: