Vanderbilt Assessment Scale-Parent Informant #6175

myADHD.com.
Vanderbilt Assessment Scale—Parent Informant # 6175.

Name of child:___________________ Gender:______ Age:___ Grade:_____Date: ____________

Completed by: _________________________ Parent's Phone Number: ______________________

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 behavior in the past 6 months.

Is this evaluation based on a time the child __ was on medication __ was not on medication __ not sure?

		Never	Occasionally	Often	Very Often
Symptoms		Never	Occasionally	Often	Very Often
1.	Does not pay close attention to details or makes careless mistakes with, for example, homework	0	1	2	3
2.	Has difficulty keeping attention to what needs to be done	0	1	2	3
3.	Does not seem to listen when spoken to directly	0	1	2	3
4.	Does not follow through on instructions and fails to finish schoolwork, chores, or duties	0	1	2	3
5.	Has difficulty organizing tasks and activities	0	1	2	3
6.	Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)	0	1	2	3
7.	Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)	0	1	2	3
8.	Is distracted by extraneous stimuli	0	1	2	3
9.	Is forgetful in daily activities	0	1	2	3
10.	Fidgets with hands or feet or squirms in seat	0	1	2	3
11.	Leaves seat in classroom or in other situations in which remaining seated is expected	0	1	2	3
12.	Runs about or climbs excessively in situations in which remaining seated is expected	0	1	2	3
13.	Has difficulty playing or engaging in leisure activities quietly	0	1	2	3
14.	Is "on the go" or often acts as if "driven by a motor"	0	1	2	3
15.	Talks excessively	0	1	2	3
16.	Blurts out answers before questions have been completed	0	1	2	3
17.	Has difficulty waiting in line	0	1	2	3
18.	Interrupts or intrudes on others (eg, butts into conversations/games)	0	1	2	3
19.	Argues with adults	0	1	2	3
20.	Loses temper	0	1	2	3
21.	Actively defies or refuses to go along with adult requests or rules	0	1	2	3
22.	Deliberately annoys people	0	1	2	3
23.	Blames others for his or her mistakes or misbehaviors	0	1	2	3
24.	Is touchy or easily annoyed by others	0	1	2	3
25.	Is angry or resentful	0	1	2	3
26.	Is spiteful and wants to get even	0	1	2	3
27.	Bullies, threatens, or intimidates others	0	1	2	3
28.	Starts physical fights	0	1	2	3
29.	Lies to get out of trouble or to avoid obligations (ie, "cons" others)	0	1	2	3
30.	Is truant from school (skips school) without permission	0	1	2	3
31.	Is physically cruel to people	0	1	2	3
32.	Has stolen things that have value	0	1	2	3
33.	Deliberately destroys others' property	0	1	2	3
34.	Has used a weapon that can cause serious harm (bat, knife, brick, gun)	0	1	2	3
35.	Is physically cruel to animals	0	1	2	3
36.	Has deliberately set fires to cause damage	0	1	2	3
37.	Has broken into someone else's home, business or car	0	1	2	3
38.	Has stayed out at night without permission	0	1	2	3
39.	Has run away from home overnight	0	1	2	3
40.	Has forced someone into sexual activity	0	1	2	3
41.	Is fearful, anxious, or worried	0	1	2	3
42.	Is afraid to try new things for fear of making mistakes	0	1	2	3
43.	Feels worthless or inferior	0	1	2	3
44.	Blames self for problems, feels guilty	0	1	2	3
45.	Feels lonely, unwanted, or unloved; complains that "no one loves him or her"	0	1	2	3
46.	Is sad, unhappy, or depressed	0	1	2	3
47.	Is self-conscious or easily embarrased	0	1	2	3

..	Performance Academic Performance	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
48.	Reading	1	2	3	4	5
49.	Mathematics	1	2	3	4	5
50.	Written expression	1	2	3	4	5
.	*Classroom Behavioral Performance*	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
51.	Relationship with peers	1	2	3	4	5
52.	Following directions	1	2	3	4	5
53.	Disrupting class	1	2	3	4	5
54.	Assignment completion	1	2	3	4	5
55.	Organizational skills	1	2	3	4	5