Vanderbilt Follow-up

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

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

was on a medicationwas not on a medicationnot 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 behaviors.
Part 1: Symptoms (Questions 1–18)

Rating Scale:

Never = 0
Occasionally = 1
Often = 2
Very Often = 3
1. Does not pay attention to details or makes careless mistakes with, for example, homework*

0 = Never1 = Occasionally2 = Often3 = Very Often
2. Has difficulty keeping attention to what needs to be done*

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 activities (not due to refusal 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 does not want to start tasks that require ongoing mental effort*

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

0 = Never1 = Occasionally2 = Often3 = Very Often
8. Is easily distracted by noises or other 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 when remaining seated is expected*

0 = Never1 = Occasionally2 = Often3 = Very Often
12. Runs about or climbs too much when remaining seated is expected*

0 = Never1 = Occasionally2 = Often3 = Very Often
13. Has difficulty playing or beginning quiet play activities*

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 too much*

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’ conversations and/or activities*

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. Overall school performance*

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

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

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

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
23. Relationship with parents*

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
24. Relationship with siblings*

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

1 = Problematic2 = Somewhat of a Problem3 = Average4 = Above Average5 = Excellent
26. Participation in organized activities (e.g., teams, clubs)*

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 Total
Should be Empty:

Vanderbilt Assessment Follow-Up – Parent Version