FOLLOW-UP FORM

Vanderbilt ADHD Follow-up (Parent)

NICHQ Vanderbilt Assessment FOLLOW-UP — PARENT Informant

Information

Today's Date This field is required

Child's Name This field is required

Child's Date of Birth This field is required

Parent's Name This field is required

Parent's Phone Number This field is required

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… *

was on medication was not on medication not sure

Please choose one

Symptoms

0 = Never · 1 = Occasionally · 2 = Often · 3 = Very Often

1. Does not pay attention to details or makes careless mistakes with, for example, homework

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

2. Has difficulty keeping attention to what needs to be done

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

3. Does not seem to listen when spoken to directly

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

5. Has difficulty organizing tasks and activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

8. Is easily distracted by noises or other stimuli

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

9. Is forgetful in daily activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

10. Fidgets with hands or feet or squirms in seat

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

11. Leaves seat when remaining seated is expected

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

12. Runs about or climbs too much when remaining seated is expected

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

13. Has difficulty playing or beginning quiet play activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

14. Is “on the go” or often acts as if “driven by a motor”

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

15. Talks too much

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

16. Blurts out answers before questions have been completed

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

17. Has difficulty waiting his or her turn

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

18. Interrupts or intrudes in on others’ conversations and/or activities

0 Never 1 Occasionally 2 Often 3 Very Often

Please choose one

Performance

1 = Excellent · 2 = Above Average · 3 = Average · 4 = Somewhat of a Problem · 5 = Problematic

19. Overall school performance

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

20. Reading

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

21. Writing

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

22. Mathematics

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

23. Relationship with parents

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

24. Relationship with siblings

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

25. Relationship with peers

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

26. Participation in organized activities (eg, teams)

1 Excellent 2 Above Average 3 Average 4 Somewhat of a Problem 5 Problematic

Please choose one

Side Effects

Has your child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem?

Headache

None Mild Moderate Severe

Please choose one

Stomachache

None Mild Moderate Severe

Please choose one

Change of appetite

None Mild Moderate Severe

Please choose one

Trouble sleeping

None Mild Moderate Severe

Please choose one

Irritability in the late morning, late afternoon, or evening

None Mild Moderate Severe

Please choose one

Socially withdrawn—decreased interaction with others

None Mild Moderate Severe

Please choose one

Extreme sadness or unusual crying

None Mild Moderate Severe

Please choose one

Dull, tired, listless behavior

None Mild Moderate Severe

Please choose one

Tremors/feeling shaky

None Mild Moderate Severe

Please choose one

Repetitive movements, tics, jerking, twitching, eye blinking

None Mild Moderate Severe

Please choose one

Picking at skin or fingers, nail biting, lip or cheek chewing

None Mild Moderate Severe

Please choose one

Sees or hears things that aren’t there

None Mild Moderate Severe

Please choose one

Explain/Comments

Please explain any side effects above, or anything else you would like the provider to know (optional)

Prefer paper? Download the blank printable form

Side effects section adapted from the Pittsburgh side effects scale, developed by William E. Pelham, Jr, PhD. 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. The information contained in this form should not be used as a substitute for the medical care and advice of your pediatrician.

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