Vanderbilt Follow-Up Parent Informant
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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. Please think about your child's behaviors since the last assessment scale was filled out when rating his/her behavior.
*
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
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.
*
Rows
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
19.Overall school performance
20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings (if child has no siblings, please check "average")
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?
*
Rows
None
Mild
Moderate
Severe
Headache
Stomachache
Change of appetite—explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening—explain below
Socially withdrawn—decreased interaction with others
Extreme sadness or unusual crying
Dull, tired, listless behavior
Tremors/feeling shaky
Repetitive movements, tics, jerking, twitching, eye blinking—explain below
Picking at skin or fingers, nail biting, lip or cheek chewing—explain below
Sees or hears things that aren’t there
Explain/Comments
Submit
Never = 0, Occasionally = 1, Often = 2, Very Often = 3
Excellent = 1, Above Average = 2, Average = 3, Somewhat a Problem = 4, Problematic = 5
The parent and teacher follow-up scales have the first 18 core ADHD symptoms, not the co-morbid symptoms.The section segment has the same Performance items and impairment assessment as the initial scales,and then has a side-effect reporting scale that can be used to both assess and monitor the presence of adverse reactions to medications prescribed, ifany. Scoring the follow-up scales involves only calculating a total symptom score for items 1–18 that can be tracked over time, and the average of the Performance items answered as measures of improvement over time with treatment. Parent Assessment Follow-up ■Calculate Total Symptom Score for questions 1–18. ■Calculate Average Performance Score for questions 19–26. Teacher Assessment Follow-up ■Calculate Total Symptom Score for questions 1–18. ■Calculate Average Performance Score for questions 19–26.
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