Combined Vanderbilt

Vanderbilt

I am a... // Soy...

PARENT, and it's my FIRST TIME filling out this form for the patient.PARENT, and I have filled out this form before for the patient.TEACHER, and it's my FIRST TIME filling out this form for the patient.TEACHER, and I have filled out this form before for the patient.

Vanderbilt Parent Initial

Today,s Date/Fecha de hoy

Date

Childs Name / Nombre del niño/a*

Date of Birth / Fecha de nacimiento*

Parents Name / Nombre del padre yo de la madre*

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.

Instrucciones: Conteste basándose en lo que considera apropiado para un niño de esa edad. Al completar este cuestionario, piense por favor en la conducta de su niño durante los últimos seis meses.

This evaluation based on a time when the child / Esta evaluacion se refiere a un periodo en el que se hijo(a)*

Was on medication / Tomaba medicamentosWas not on medication / No tomaba medicamentosNot sure/ No lo recuerda

What medication, if any, is the child taking? // ¿Qué medicamento, si es que toma alguno, está tomando el niño?

INATTENTION SCORE: Total number of questions scored 2 or 3 in Inattention questions (6 out of 9 AND 4 or 5 in any Performance questions 48-55):

HYPERACTIVITY SCORE: Total number of questions scored 2 or 3 in hyperactivity questions (6 out of 9 AND score a 4 or 5 in any Performance questions 48-55):

OPPOSITIONAL DEFIANCE SCORE: Total number of questions scored 2 or 3 in Oppositional Defiant questions (4 out of 8 AND score a 4 or 5 in any Performance questions 48-55):

CONDUCT DISORDER SCORE: Total number of questions scored 2 or 3 in Conduct Disorder questions 27-40 (3 out of 14 AND score a 4 or 5 in any Performance questions 48-55):

ANXIETY/DEPRESSION SCORE: Total number of questions scored 2 or 3 in Depression questions 41-47 (3 out of 7 AND score a 4 or 5 in any Performance questions 48-55)

PERFORMANCE SCORE: Total number of questions scored 4 or 5 any Performance questions 48-55

INATTENTION*

	Never	Occa-sionally	Often	Very Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework / No pone atencion a los detalles o comete errores por descuido, como por ejemplo, cuado hace la tarea
2. Has difficulty keeping attention to what needs to be done / De le dificulta mantenerse atento al llevar a cabo sus actividades
3. Does not seem to listen when spoken to directly / Parece no estar escuchando cuando se le habla directamente
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) / No sigue las instrucciones hasta el final y no concluye sus actividads (no porque se rehuse a seguirlas o porque no las comprenda)
5. Has difficulty organizing tasks and activities / Tiene dificultad al organizar sus tareas diarias y actividades
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort / Evita, le disgusta o no quiere comenzar actividades que requieren un mayor esfuerzo mental
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) / Pierde cosas que son indispensables para cumplir con sus tareas o actividades (juguetes, tareas de la escuela, lapices o libros)
8. Is easily distracted by noises or other stimuli / Se distrae facilmente con ruidos u otros estimulos externos
9. Is forgetful in daily activities / Es olvidadizo(a) en sus actividades cotidianas

HYPERACTIVITY*

	Never	Occa-sionally	Often	Very Often
10. Fidgets with hands or feet or squirms in seat / Mueve constantement las manos or los pies o no se esta quieto(a) en su asiento
11. Leaves seat when remaining seated is expected / Se pone de pie cuando debiera permanecer sentado(a)
12. Runs about or climbs too much when remaining seated is expected / Corre o camina por todos lados cuando debiera permanecer sentado
13. Has difficulty playing or beginning quiet play activities / Se le dificulta jugar o empezar actividades recreativas mas tranquilas
14. Is "on the go" or often acts as if "driven by a motor" / Esta en constante movimiento o actua como si "tuviera un motor por dentro"
15. Talks too much / Habla demasiado
16. Blurts out answers before questions have been completed / Responde precitadamente, incluso antes de escuchar la pregunta completa
17. Has difficulty waiting his or her turn / Tiene dificultad al esperar su turno
18. Interrupts or intrudes in on others' conversations and/or activities / Interrumpe o se entromete en conversaciones o actividades ajenas

OPPOSITIONAL DEFIANCE DISORDER*

	Never	Occa-sionally	Often	Very Often
19. Argues with adults / Discute con adultos
20. Loses temper / Se enfurece con facilidad
21. Actively defies or refuses to go along with adults' requests or rules / Desafia abiertamente o se niega a cumplir la ordenes o las reglas de los adultos
22. Deliberately annoys people / Molesta adrede a los demas
23. Blames others for his or her mistakes or misbehaviors / Culpa a otros de sus propios errores o se mal comportamiento
24. Is touchy or easily annoyed by others / Se ofende o se molesta facilmente conotros
25. Is angry or resentful / Esta enojado(a) or resentido(a)
26. Is spiteful and wants to get even / Es rensoroso y vengativo

CONDUCT DISORDER*

	Never	Occa-sionally	Often	Very Often
27. Bullies, threatens, or intimidates / others / Reta, amenaza o intimida o otros
28. Starts physical fights / Comienza pelas de contacto fisico
29. Lies to get out of trouble or to avoid obligations (ie, "cons" others) / Miente con el fin de salir de apuros o para eludir sus obligaciones
30. Is truant from school (skips school) without permission / Falta a la escuela sin permiso
31. Is physically cruel to people / Es fisicamente cruel con los demas
32. Has stolen things that have value / Ha robado cosas de valor
33. Deliberately destroys others' property / Destruye deliberadamente la propiedad ajena
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) / Has usado un objeto que puede herir a alguien (bate, cuchillo, ladrillo, pistola)
35. Is physically cruel to animals / Tortura animales
36. Has deliberately set fires to cause damage / Ha provocado fuegos par causar danos
37. Has broken into someone else's home, business, or car / Ha entrado a una casa, un negocio on un carro ajeno
38. Has stayed out at night without permission / Ha permanecido fuera de la casa sin permiso durante la noche
39. Has run away from home overnight / Se has escapado de la casa durante la noche
40. Has forced someone into sexual activity / ha obligado a alguien a sostener algun tipo de actividade sexual

ANXIETY/DEPRESSION*

	Never	Occasionally	Often	Very Often
41. Is fearful, anxious, or worried / Siente miedo, ansiedad o esta preocupado
42. Is afraid to try new things for fear of making mistakes / Teme hacer nuevas coasa por temor a cometer
43. Feels worthless or inferior / Se desprecia a si mismo se siento inferior
44. Blames self for problems, feels guilty / Siente que los problemas son responsabilidad suya y se siente culpable
45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her" / Se siente solo(a), rechazado(a), o sin amor; se queja de que nadie lo quiere
46. Is sad, unhappy, or depressed / Se siente triste, infeliz o deprimido(a)
47. Is self-conscious or easily embarrassed / Esta al pendiente de sus actos o se averguenza facilmente

PERFORMANCE*

	Excellent	Above Average	Average	Somewhat of a problem	Problematic
48. Overall school performance / Comportamiento general en la escuela
49. Reading / Lectura
50. Writting / Escritura
51. Mathematics / Matematicas
52. Relationship with parents / Relacion con sus padres
53. Relationship with siblings / Relacion con sus hermanos
54. Relationship with peers / Relacion son sus compañeros
55. Participation in organized activities (for example: teams) / Participacion en actividades organizadas (ejemplo: equipos deportivos)

Comments

Vanderbilt Parent Follow Up

Todays Date/ Fecha de hoy*

Date

Childs Name/ Nombre del niño(a)*

First NameLast Name

Date of Birth/Fecha de nacimiento *

Parents Name/ Nombre del padre o de la madre*

Total Inattention Score:

Total Hyperactivity score:

Total performance

Average Performance

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.

Intrucciones: Conteste basandose en lo que considera apropiado para un niño de esa edad. Al completar este cuestionario, piense por favor en la conducta de su niño(a) desde la ultima vez que lleno el primer cuestionario.

Is this evaluation based on a time when the child/Durante el periodo de evaluacion su hijo(a)*

Was on medication/Tomaba medicamentosWas not on medication/ No tomaba medicamentosNot sure/ No lo recuerda

What medication, if any, is the child taking? // ¿Qué medicamento, si es que toma alguno, está tomando el niño?*

INATTENTION*

	Never/ Nunca	Occa-sionally/ A veces	Often/ Seguido	Very Often/ Muy seguido
1. Does not pay attention to details or makes careless mistakes with, for example, homework/ No pone atencion a los detalles o comete errores por descuido como por ejemplo, cuando hace la tarea
2. Has difficulty keeping attention to what needs to be done/ Se le dificulta mantenerse atento al llevar a cabo sus actividades
3. Does not seem to listen when spoken to directly/ Parece no estar escuchando cuando se le habla directamente
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) /No sigue las instrucciones hasta el final y no concluye sus actividades (no por que se rehuse a seguirlas o por que no la comprenda)
5. Has difficulty organizing tasks and activities / Tiene dificultad al organizar sus tareas y actividdes
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort/ Evita, le disgusta o no quiere comenzar actividades que requieren un continuo esfuerzo mental
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)/Pierde cosas que son indispensables para cumplir con sus tareas o actividades(juguetes, tareas de le escuela, lapices o libros)
8. Is easily distracted by noises or other stimuli/ Se distrae facilmente con ruidos u otros estimulos externos
9. Is forgetful in daily activities/ Es olvidadizo (a) en sus actividades cotidianas

HYPERACTIVITY*

	Never/ Nunca	Occasionally/ A veces	Often/ Seguido	Very Often/ Muy seguido
10. Fidgets with hands or feet or squirms in seat / Mueve constantemente las manos o los pies, o no se esta quieto(a) en su asiento
11. Leaves seat when remaining seated is expected/ Se pone de pie cuando debiera permanecer sentado(a)
12. Runs about or climbs too much when remaining seated is expected/ Corre o camina por todos lados cuando deberia permanecer sentado
13. Has difficulty playing or beginning quiet play activities/ se le difficulta jugar o empezar actividades recreativas mas tranquilas
14. Is "on the go" or often acts as if "driven by a motor"/ Esta en constante movimiento o actua como si "tuviera un motor por dentro"
15. Talks too much/ Habla demasiado
16. Blurts out answers before questions have been completed/ Responde prescipitadamente, incluso antes de escuchar la pregunta completa
17. Has difficulty waiting his or her turn / Tiene dificultad al esperar su turno
18. Interrupts or intrudes in on others' conversations and/or activities/ Interrumpe o se entromente en conversaciones o actividades ejenas

PERFORMANCE*

	Excellent/ Excelente	Above Average/ Sobre lo normal	Average/ Normal	Somewhat of a problem/ Cierta dificultad	Problematic/ Con dificultad	Unable to Assess
19. Overall school performance/ Comportamiento general en la escuela
20. Reading/ Lectura
21. Writting/ Escritura
22. Mathematics/ Matematicas
23. Realtionship with parents/ Relacion con sus padres
24. Relationship with siblings/ Relacion con sus hermanos
25. Relationship with peers/ Relacion con sus compañeros
26. Participation in organized activities (for example: teams)/ Participacion en activdades organizadas (ejemplo: equipos deportivos)

Side Effects: Has the child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem? // Efectos colaterales: Durante la semana pasada, ¿ha padecido su hijo(a) alguno de los siguientes problemas de salud o posibles efectos colaterales del tratamiento? ¿Estos efectos son un problema actual? *

	None/ No	Mild/ Leve	Moderate/ Moderado	Severe/ Severo
Headache/ Dolor de cabeza
Stomachache/ Dolor de estomago
Change of appetite (please explain below)/Alteracion del apetito (explique abajo)
Trouble sleeping/ Problemas para dormir
Irritability in the late morning, late afternoon, or evening (please explain below)/ Iritabilidad al mediodia, al anochecer o por la tardes (explique abajo)
Socially withdrawn-decreased interaction with others/Cducta antisocial (su interaccion con los otros se ha reducido)
Extreme sadness or unusual crying/ Tristeza profunda o llanto sin motivo aparente
Dull, tired, listless behavior/ Aburido(a), cansado(a), apatico(a)
Tremors/feeling shaky/ Escalofrios/siente que le tiembla el cuerpo
Repetitive movements, tics, jerking, twitching, eye blinking (please explain below)/ Movimientos involuntarios, tic nerviosos, pestañeos continuos (explique abajo)
Picking at skin or fingers, nail biting, lip or cheek chewing (please explain below)/ Se come las uñas, se rasca la peil o se muerde las labios (explique abajo)
Sees or hears things that aren't there/ Ve o escucha cosas imaginarias

Explain/ Comments: Explique/ Comentarios:

Vanderbilt Teacher Initial

Todays Date*

Date

Childs Name*

Grade Level*

Teachers Name*

Class Name Period*

Class Time*

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 beginning of the school year.

Please indicate the number of months you have been able to evaluate the child's behaviors.*

This evaluation based on a time when the child*

Was on medicationWas not on medicationNot sure

INATTENTION:Total number of questions scored 2 or 3 in Inattention questions (6 out of 9 AND 4 or 5 in any Performance questions 36-43):

HYPERACTIVITY: Total number of questions scored 2 or 3 in hyperactivity questions (6 out of 9 AND score a 4 or 5 in any Performance questions 36-43):

OPPOSITIONAL DEFIANCE: Total number of questions scored 2 or 3 in Oppositional Defiant/Conduct Disorder questions (3 out of 10 AND score a 4 or 5 in any Performance questions 36-43):

ANXIETY/DEPRESSION: Total number of questions scored 2 or 3 in Anxiety/Depression questions 29-35 (3 out of 7 AND score a 4 or 5 in any Performance questions 36-43)

ACADEMIC/CLASSROOM BEHAVIOR PERFORMANCE: Total number of questions scored a 4 or 5 in any Performance questions 36-43)

INATTENTION*

	Never	Occa- sionally	Often	Very Often
1. Fails to give attention to details or makes careless mistakes in schoolwork
2. Has difficulty sustaining attention to tasks or activities
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork (not due to oppositional behavior or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
7. Loses things necessary for tasks or activities (school assignments, pencils, or books)
8. Is easily distracted by extraneous stimuli
9. Is forgetful in daily activities

HYPERACTIVITY*

	Never	Occa-sionally	Often	Very Often
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat in classroom or in other situations in which remaining seated is expected
12. Runs about or climbs excessively in situations in which remaining seated is expected
13. Has difficulty playing or engaging in leisure activities quietly
14. Is "on the go" or often acts as if "driven by a motor"
15. Talks excessively
16. Blurts out answers before questions have been completed
17. Has difficulty waiting in line
18. Interrupts or intrudes on others (eg, butts into conversations/games)

OPPOSITIONAL DEFIANT/CONDUCT DISORDER*

	Never	Occa-sionally	Often	Very Often
19. Loses temper
20. Actively defies or refuses to comply with adult's requests or rules
21. Is angry or resentful
22. Is spiteful and vindictive
23. Bullies, threatens, or intimidates others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (eg, "cons" others)
26. Is physically cruel to people
27. Has stolen items of nontrivial value
28. Deliberately destroys others' property

ANXIETY/DEPRESSION*

	Never	Occa-sionally	Often	Very Often
29. Is fearful, anxious, or worried
30. Is self-conscious or easily embarrassed
31. Is afraid to try new things for fear of making mistakes
32. Feels worthless or inferior
33. Blames self for problems; feels guilty
34. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
35. Is sad, unhappy, or depressed

ACADEMIC PERFORMANCE*

	Excellent	Above Average	Average	Somewhat of a problem	Problematic
36. Reading
37. Mathematics
38. Written expression

CLASSROOM BEHAVIORAL PERFORMANCE*

	Excellent	Above Average	Average	Somewhat of a problem	Problematic
39. Relationship with peers
40. Following direction
41. Disrupting class
42. Assignment completion
43. Organizational skills

Comments

Vanderbilt Teacher Follow Up

Todays Date*

Date

Childs Name*

Grade Level*

Teachers Name*

Class Time*

Class Name Period*

This evaluation based on a time when the child*

Was on medicationWas not on medicationNot sure

Total Inattention Score:

Total Hyperactivity score:

Total performance

Average Performance

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 months you have been able to evaluate the child's behaviors.*

INATTENTION*

	Never	Occa-sionally	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 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 distracted by noises or other stimuli
9. Is forgetful in daily activities

HYPERACTIVITY*

	Never	Occa-sionally	Often	Very Often
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 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 or her turn
18. Interrupts or intrudes in on others' conversations and/or activities

PERFORMANCE*

	Excellent	Above Average	Average	Somewhat of a problem	Problematic
19. Reading
20. Mathematics
21. Written expression
22. Relationship with peers
23. Following direction
24. Disrupting class
25. Assignment completion
26. Organizational skills

Side Effects: Has the child experienced any of the following side effects or problems in the past week? *

	None	Mild	Moderate	Severe
Headache
Stomachache
Change of appetite (please explain below)
Trouble sleeping
Irritability in the late morning, late afternoon, or evening (please 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 (please explain below)
Picking at skin or fingers, nail biting, lip or cheek chewing (please explain below)
Sees or hears things that aren't there

Are these side effects currently a problem? Please explain and enter additional comments below.