NICHQ Vanderbilt Assessment - Parent Informant

NICHQ Vanderbilt Assessment - Parent Informant

Each rating should be considered in the context of what is appropriate for the age of your child. When completing this form, please think about your child's behaviors in the past 6 months.
Patient Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Is this evaluation based on a time when the child...*

was on medication?was not on medication?not sure?
Does not pay attention to details or makes careless mistakes with, for example, homework*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has difficulty keeping attention to what needs to be done*

Never (0)Occasionally (1)Often (2)Very Often (3)
Does not seem to listen when spoken to directly*

Never (0)Occasionally (1)Often (2)Very Often (3)
Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has difficulty organizing tasks and activities*

Never (0)Occasionally (1)Often (2)Very Often (3)
Avoids, dislikes, or does not want to start tasks that require ongoing mental effort*

Never (0)Occasionally (1)Often (2)Very Often (3)
Loses things things necessary for tasks or activities (toys, assignments, pencils, or books)*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is easily distracted by noises or other stimuli*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is forgetful in daily activities*

Never (0)Occasionally (1)Often (2)Very Often (3)
Fidgets with hands or feet or squirms in seat*

Never (0)Occasionally (1)Often (2)Very Often (3)
Leaves seat when remaining seated is expected*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has difficulty playing or beginning quiet play activities*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is "on the go" or often acts as if "driven by a motor"*

Never (0)Occasionally (1)Often (2)Very Often (3)
Talks too much*

Never (0)Occasionally (1)Often (2)Very Often (3)
Blurts out answers before questions have been completed*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has difficulty waiting his or her turn*

Never (0)Occasionally (1)Often (2)Very Often (3)
Interrupts or intrudes in on others' conversations and/or activities*

Never (0)Occasionally (1)Often (2)Very Often (3)
Argues with adults*

Never (0)Occasionally (1)Often (2)Very Often (3)
Loses temper*

Never (0)Occasionally (1)Often (2)Very Often (3)
Actively defies or refuses to go along with adults' requests or rules*

Never (0)Occasionally (1)Often (2)Very Often (3)
Deliberately annoys people*

Never (0)Occasionally (1)Often (2)Very Often (3)
Blames others for his or her mistakes or misbehaviors*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is touchy or easily annoyed by others*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is angry or resentful*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is spiteful and wants to get even*

Never (0)Occasionally (1)Often (2)Very Often (3)
Bullies, threatens, or intimidates others*

Never (0)Occasionally (1)Often (2)Very Often (3)
Starts physical fights*

Never (0)Occasionally (1)Often (2)Very Often (3)
Lies to get out of trouble or to avoid obligations (ie, "cons" others)*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is truant from school (skips school) without permission*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is physically cruel to people*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has stolen things that have value*

Never (0)Occasionally (1)Often (2)Very Often (3)
Deliberately destroys others' property*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has used a weapon that can cause serious harm (bat, knife, brick, gun)*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is physically cruel to animals*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has deliberately set fires to cause damage*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has broken into someone else's home, business, or car*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has stayed out at night without permission*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has run away from home overnight*

Never (0)Occasionally (1)Often (2)Very Often (3)
Has forced someone into sexual activity*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is fearful, worried, or anxious*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is afraid to try new things for fear of making mistakes*

Never (0)Occasionally (1)Often (2)Very Often (3)
Feels worthless or inferior*

Never (0)Occasionally (1)Often (2)Very Often (3)
Blames self or problems, feels guilty*

Never (0)Occasionally (1)Often (2)Very Often (3)
Feels lonely, unwanted, or unloved; complains that "no one loves him or her"*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is sad, unhappy, or depressed*

Never (0)Occasionally (1)Often (2)Very Often (3)
Is self-conscious or easily embarrassed*

Never (0)Occasionally (1)Often (2)Very Often (3)

NICHQ Vanderbilt Assessment - Parent Informant

Performance