Vanderbilt Initial Parent Informant
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Name of Person filling out the form
*
First Name
Last Name
Relationship to Patient
*
Is this evaluation based on a time when the child;
*
was on medication
was not on medication
not sure
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.
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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 on instructions 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 games
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. Often lies to get out of trouble, obtain goods or favors, or to avoid obligations (ie, "cons" others)
30. Is often truant from school (skips school) without permission
31. Has been 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. Has been 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
Please choose the response that best describes your child's performance in the following area in the past 6 months. Each rating should be considered in the context of what is appropriate for the age of your child.
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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 (if child has no siblings, please check "average")
54. Relationship with peers
55. Participation in organized activities (eg, teams)
Comments
Submit
Never = 0, Occasionally = 1, Often = 2, Very Often = 3
Excellent = 1, Above Average = 2, Average = 3, Somewhat a problem = 4, Problematic = 5
Should be Empty: