southfieldpeds.com - ADHD Parent Questionnaire

Today’s Date:

Date

Child’s Name:

Date of Birth:

Date

Parent’s Name:

Parent’s Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Directions: 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.

Is this evaluation based on a time when the child

Symptoms

Rows	Never	Occasionally	Often	Very Often
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
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to go along with adults’ requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or resentful
26. Is spiteful and wants to get even
27. Bullies, threatens, or intimidates others
28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (ie,“cons” others)
30. Is truant from school (skips school) without permission
31. Is physically cruel to people
32. Has stolen things that have value
33. Deliberately destroys others’ property
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35. Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone else’s home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed

1. Total:

1. Never

1. Occasionally

1. Often

1. Very Often

2. Total:

2. Never

2. Occasionally

2. Often

2. Very Often

3. Total:

3. Never

3. Occasionally

3. Often

3. Very Often

4. Total

4. Never

4. Occasionally

4. Often

4. Very Often

5. Total

5. Never

5. Occasionally

5. Often

5. Very Often

6. Total

6. Never

6. Occasionally

6. Often

6. Very Often

7. Total

7. Never

7. Occasionally

7. Often

7. Very Often

8. Total

8. Never

8. Occasionally

8. Often

8. Very Often

9. Total

9. Never

9. Occasionally

9. Often

9. Very Often

10. Total

10. Never

10. Occasionally

10. Often

10. Very Often

11. Total

11. Never

11. Occasionally

11. Often

11. Very Often

12. Total

12. Never

12. Occasionally

12. Often

12. Very Often

13. Total

13. Never

13. Occasionally

13. Often

13. Very Often

14. Total

14. Never

14. Occasionally

14. Often

14. Very Often

15. Total

15. Never

15. Occasionally

15. Often

15. Very Often

16. Total

16. Never

16. Occasionally

16. Often

16. Very Often

17. Total

17. Never

17. Occasionally

17. Often

17. Very Often

18. Total

18. Never

18. Occasionally

18. Often

18. Very Often

19. Total

19. Never

19. Occasionally

19. Often

19. Very Often

20. Total

20. Never

20. Occasionally

20. Often

20. Very Often

21. Total

21. Never

21. Occasionally

21. Often

21. Very Often

22. Total

22. Never

22. Occasionally

22. Often

22. Very Often

23. Total

23. Never

23. Occasionally

23. Often

23. Very Often

24. Total

24. Never

24. Occasionally

24. Often

24. Very Often

25. Total

25. Never

25. Occasionally

25. Often

25. Very Often

26. Total

26. Never

26. Occasionally

26. Often

26. Very Often

27. Total

27. Never

27. Occasionally

27. Often

27. Very Often

28. Total

28. Never

28. Occasionally

28. Often

28. Very Often

29. Total

29. Never

29. Occasionally

29. Often

29. Very Often

30. Total

30. Never

30. Occasionally

30. Often

30. Very Often

31. Total

31. Never

31. Occasionally

31. Often

31. Very Often

32. Total

32. Never

32. Occasionally

32. Often

32. Very Often

33. Total

33. Never

33. Occasionally

33. Often

33. Very Often

34. Total

34. Never

34. Occasionally

34. Often

34. Very Often

35. Total

35. Never

35. Occasionally

35. Often

35. Very Often

36. Total

36. Never

36. Occasionally

36. Often

36. Very Often

37. Total

37. Never

37. Occasionally

37. Often

37. Very Often

38. Total

38. Never

38. Occasionally

38. Often

38. Very Often

39. Total

39. Never

39. Occasionally

39. Often

39. Very Often

40. Total

40. Never

40. Occasionally

40. Often

40. Very Often

41. Total

41. Never

41. Occasionally

41. Often

41. Very Often

42. Total

42. Never

42. Occasionally

42. Often

42. Very Often

43. Total

43. Never

43. Occasionally

43. Often

43. Very Often

44. Total

44. Never

44. Occasionally

44. Often

44. Very Often

45. Total

45. Never

45. Occasionally

45. Often

45. Very Often

46. Total

46. Never

46. Occasionally

46. Often

46. Very Often

47. Total

47. Never

47. Occasionally

47. Often

47. Very Often

Total Never

Total Occasionally

Total Often

Total Very Often

Performance

Rows	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
48. Overall school performance
49. Reading
50. Writing
51. Mathematics
52. Relationship with parents
53. Relationship with siblings
54. Relationship with peers
55. Participation in organized activities (eg, teams)

48. Total

48. Excellent

48. Above Average

48. Average

48. Somewhat Problem

48. Problematic

49. Total

49. Excellent

49. Above Average

49. Average

49. Somewhat Problem

49. Problematic

50. Total

50. Excellent

50. Above Average

50. Average

50. Somewhat Problem

50. Problematic

51. Total

51. Excellent

51. Above Average

51. Average

51. Somewhat Problem

51. Problematic

52. Total

52. Excellent

52. Above Average

52. Average

52. Somewhat Problem

52. Problematic

53. Total

53. Excellent

53. Above Average

53. Average

53. Somewhat Problem

53. Problematic

54. Total

54. Excellent

54. Above Average

54. Average

54. Somewhat Problem

54. Problematic

55. Total

55. Excellent

55. Above Average

55. Average

55. Somewhat Problem

55. Problematic

Total Excellent

Total Above Average

Total Average

Total Somewhat Problem

Problematic

Comments:

For Office Use Only

Total number of questions scored 2 or 3 in questions 1–9:
Total number of questions scored 2 or 3 in questions 10–18:

Total Symptom Score for questions 1–18:

Total number of questions scored 2 or 3 in questions 19–26:
Total number of questions scored 2 or 3 in questions 27–40:
Total number of questions scored 2 or 3 in questions 41–47:
Total number of questions scored 4 or 5 in questions 48–55:

Average Performance Score:

NICHQ Vanderbilt Assessment — parent

Symptom Totals

Count of 'Never': {totalNever}

Count of 'Occasionally': {totalOccasionally}

Count of 'Often': {totalOften}

Count of 'Very Often': {totalVery}

Performance Totals

Count of 'Excellent': {totalExcellent}

Count of 'Above Average': {totalAbove}

Count of 'Average': {totalAverage}

Count of 'Somewhat of a Problem': {totalSomewhat}

Count of 'Problematic': {problematic}

NICHQ Vanderbilt Assessment Scale—PARENT Informant

NICHQ Vanderbilt Assessment — parent

Symptom Totals

Performance Totals