Vanderbilt Follow-up

Vanderbilt Assessment Follow-Up – Teacher Version
Patient Name:*
Teacher Name:*
Today's Date:*

MonthDayYear
Date
Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the last assessment scale was filled out.
Please indicate the number of weeks or months you have been able to evaluate the behaviors:*
Is this evaluation based on a time the child*

was on a medicationwas not on a medicationnot sure?
Part 1: Symptoms (Questions 1–18)

Rating Scale:

Never = 0
Occasionally = 1
Often = 2
Very Often = 3
1. Fails to give close attention to details or makes careless mistakes in schoolwork*

0 = Never1 = Occasionally2 = Often3 = Very Often
2. Has difficulty sustaining attention to tasks or activities*

0 = Never1 = Occasionally2 = Often3 = Very Often
3. Does not seem to listen when spoken to directly*

0 = Never1 = Occasionally2 = Often3 = Very Often
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)*

0 = Never1 = Occasionally2 = Often3 = Very Often
5. Has difficulty organizing tasks and activities*

0 = Never1 = Occasionally2 = Often3 = Very Often
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort*

0 = Never1 = Occasionally2 = Often3 = Very Often
7. Loses things necessary for tasks or activities (e.g., pencils, books, tools)*

0 = Never1 = Occasionally2 = Often3 = Very Often
8. Is easily distracted by extraneous stimuli*

0 = Never1 = Occasionally2 = Often3 = Very Often
9. Is forgetful in daily activities*

0 = Never1 = Occasionally2 = Often3 = Very Often
10. Fidgets with hands or feet or squirms in seat*

0 = Never1 = Occasionally2 = Often3 = Very Often
11. Leaves seat in classroom or in other situations in which remaining seated is expected*

0 = Never1 = Occasionally2 = Often3 = Very Often
12. Runs about or climbs excessively in situations where it is inappropriate*

0 = Never1 = Occasionally2 = Often3 = Very Often
13. Has difficulty playing or engaging in leisure activities quietly*

0 = Never1 = Occasionally2 = Often3 = Very Often
14. Is “on the go” or often acts as if “driven by a motor”*

0 = Never1 = Occasionally2 = Often3 = Very Often
15. Talks excessively*

0 = Never1 = Occasionally2 = Often3 = Very Often
16. Blurts out answers before questions have been completed*

0 = Never1 = Occasionally2 = Often3 = Very Often
17. Has difficulty waiting for his or her turn*

0 = Never1 = Occasionally2 = Often3 = Very Often
18. Interrupts or intrudes on others (e.g., butts into conversations or games)*

0 = Never1 = Occasionally2 = Often3 = Very Often
Section 2: Performance – Items 19–26

Rating Scale:

1 = Problematic
2 = Somewhat of a Problem
3 = Average
4 = Above Average
5 = Excellent
19. Reading*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
20. Mathematics*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
21. Written expression*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
22. Relationship with peers*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
23. Following directions/rules*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
24. Disrupting class*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
25. Assignment completion*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
26. Organizational skills*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
Side Effects: Has the child experienced any of the following side effects or problems in the past week?
Headache*

NoneMildModerateSevere
Stomachache*

NoneMildModerateSevere
Change in appetite (explain below)*

NoneMildModerateSevere
Trouble sleeping*

NoneMildModerateSevere
Irritability in the late morning, late afternoon, or evening (explain below)*

NoneMildModerateSevere
Socially withdrawn - decreased interaction with others*

NoneMildModerateSevere
Extreme sadness or unusual crying*

NoneMildModerateSevere
Dull, tired, listless behavior*

NoneMildModerateSevere
Tremors/feeling shaky*

NoneMildModerateSevere
Repetitive movements, tics, jerking, twitching, eye blinking (explain below)*

NoneMildModerateSevere
Picking at skin or fingers, nail biting, lip or cheek chewing (explain below)*

NoneMildModerateSevere
Sees or hears things that aren’t there*

NoneMildModerateSevere
Explain/Comments:
Symptom Score
Should be Empty:

Vanderbilt Assessment Follow-Up – Teacher Version