NICHQ Vanderbilt Parent Form

Does not pay attention to detais or makes careless mistakes with, for example, homework:
-NeverOccasionallyOftenVery Often

Has difficulty keeping attention to what needs to be done:
-NeverOccasionallyOftenVery Often

Does not seem to listen when spoken to directly:
-NeverOccasionallyOftenVery Often

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand):
-NeverOccasionallyOftenVery Often

Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand):
-NeverOccasionallyOftenVery Often

Has difficulty organizing tasks and activities:
-NeverOccasionallyOftenVery Often

Avoids, dislikes, or does not want to start tasks that require ongoing mental effort:
-NeverOccasionallyOftenVery Often

Loses things necessary for tasks or activities (toys, assignments, pencils, or books):
-NeverOccasionallyOftenVery Often

Is easily distracted by noises or other stimuli:
-NeverOccasionallyOftenVery Often

Is forgetful in daily activities:
-NeverOccasionallyOftenVery Often

Fidgets with hands or feet or squirms in seat:
-NeverOccasionallyOftenVery Often

Leaves seat when remaining seated is expected:
-NeverOccasionallyOftenVery Often

Runs about or climbs too much when remaining seated is expected:
-NeverOccasionallyOftenVery Often

Has difficulty playing or beginning quiet play activities :
-NeverOccasionallyOftenVery Often

Is “on the go” or often acts as if “driven by a motor”:
-NeverOccasionallyOftenVery Often

Talks too much:
-NeverOccasionallyOftenVery Often

Blurts out answers before questions have been completed:
-NeverOccasionallyOftenVery Often

Has difficulty waiting his or her turn:
-NeverOccasionallyOftenVery Often

Interrupts or intrudes in on others’ conversations and/or activities:
-NeverOccasionallyOftenVery Often

Argues with adults:
-NeverOccasionallyOftenVery Often

Loses temper:
-NeverOccasionallyOftenVery Often

Actively defies or refuses to go along with adults’ requests or rules:
-NeverOccasionallyOftenVery Often

Deliberately annoys people:
-NeverOccasionallyOftenVery Often

Blames others for his or her mistakes or misbehaviors:
-NeverOccasionallyOftenVery Often

Is touchy or easily annoyed by others:
-NeverOccasionallyOftenVery Often

Is angry or resentful:
-NeverOccasionallyOftenVery Often

Is spiteful and wants to get even:
-NeverOccasionallyOftenVery Often

Bullies, threatens, or intimidates others:
-NeverOccasionallyOftenVery Often

Starts physical fights:
-NeverOccasionallyOftenVery Often

Lies to get out of trouble or to avoid obligations (ie,“cons” others):
-NeverOccasionallyOftenVery Often

Is truant from school (skips school) without permission:
-NeverOccasionallyOftenVery Often

Is physically cruel to people:
-NeverOccasionallyOftenVery Often

Has stolen things that have value:
-NeverOccasionallyOftenVery Often

Deliberately destroys others’ property:
-NeverOccasionallyOftenVery Often

Has used a weapon that can cause serious harm (bat, knife, brick, gun):
-NeverOccasionallyOftenVery Often

Is physically cruel to animals:
-NeverOccasionallyOftenVery Often

Has deliberately set fires to cause damage:
-NeverOccasionallyOftenVery Often

Has broken into someone else’s home, business, or car:
-NeverOccasionallyOftenVery Often

Has stayed out at night without permission:
-NeverOccasionallyOftenVery Often

Has run away from home overnight:
-NeverOccasionallyOftenVery Often

Has forced someone into sexual activity:
-NeverOccasionallyOftenVery Often

Is fearful, anxious, or worried:
-NeverOccasionallyOftenVery Often

Is afraid to try new things for fear of making mistakes:
-NeverOccasionallyOftenVery Often

Feels worthless or inferior:
-NeverOccasionallyOftenVery Often

Blames self for problems, feels guilty:
-NeverOccasionallyOftenVery Often

Feels lonely, unwanted, or unloved; complains that “no one loves him or her”:
-NeverOccasionallyOftenVery Often

Is sad, unhappy, or depressed:
-NeverOccasionallyOftenVery Often

Is self-conscious or easily embarrassed:
-NeverOccasionallyOftenVery Often

Overall school performance:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Reading:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Writing:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Mathematics:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Relationship with parents:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Relationship with siblings:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Relationship with peers:
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Participation in organized activities (eg, teams):
-ExcellentAbove AverageAverageSomewhat of a ProblemProblematic

Total number of questions scored 2 or 3 in questios 1-9:

Total number of questions scored 2 or 3 in questions 10–18:

Total Symptom Score for questions 1–18:

Total number of questions scored 2 or 3 in questions 19–26:

Total number of questions scored 2 or 3 in questions 27–40:

Total number of questions scored 2 or 3 in questions 41–47:

Total number of questions scored 4 or 5 in questions 48–55:

Average Performance Score: