ADHD Parent Follow-Up Form

NICHQ Vanderbilt Assessment Follow Up

PARENT Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Name

First NameLast 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. Please think about your child's behaviors since the last assessment scale was filled out when rating his/her behaviors.
Is this evaluation based on a time when the child

Symptoms

Rows	(0) Never	(1) Occasionally	(2) Often	(3) 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 distraced 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 reamining 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/her turn
18. Interrupts or intrudes in on others' conversation and/or activites

Performance

Rows	(1) Excellent	(2) Above Average	(3) Average	(4) Somewhat of a Problem	(5) Problematic
19. Overall school performance
20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings
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	Are these side effects currently a problem? (Mark if Yes)
Headache
Stomachache
Change in appetite-explain below
Trouble sleeping
Irritability in the late morning, late afternoon, or evening-explain below
Socially withdrawn- decreased interation 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:
For Office Use Only
Total Symptom Score for questions 1-18 _____________________________
Average Performance Score for questions 19-26 _____________________
The information contained in this publication should not be used as a substitute for the
medical care and advice of your pediatrician. There may be variations in treatment that
your pediatrician may recommend based on individual facts and circumstances.
Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s
Healthcare Quality
Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.
Revised - 0303
Should be Empty:

NICHQ Vanderbilt Assessment Follow Up