NICHQ Vanderbilt ASSESSMENT Scale PARENT Informant

Associated Therapists Inc.
(714) 898-0362 Corporate Office
(714) 893-3267 Fax
www.associatedtherapists.com

Today's Date:

+

Child's First Name: *

Child's Last Name: *

Child's Age: *

Child's Grade Level:

Parents Name: *

Name of Doctor / Nurse / Therapist:

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 when the child was:

On Medication

Was Not On Medication

Not Sure

Symptoms

	Never	Occasionally	Often	Very Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework.	Never	Occasionally	Often	Very Often
2. Has difficulty keeping attention to what needs to be done.	Never	Occasionally	Often	Very Often
3. Does not seem to listen when spoken to directly.	Never	Occasionally	Often	Very Often
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand).	Never	Occasionally	Often	Very Often
5. Has difficulty organizing tasks and activities.	Never	Occasionally	Often	Very Often
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort.	Never	Occasionally	Often	Very Often
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books).	Never	Occasionally	Often	Very Often
8. Is easily distracted by noises or other stimuli.	Never	Occasionally	Often	Very Often
9. Is forgetful in daily activities.	Never	Occasionally	Often	Very Often

	Never	Occasionally	Often	Very Often
10. Fidgets with hands or feet or squirms in seat.	Never	Occasionally	Often	Very Often
11. Leaves seat when remaining seated is expected.	Never	Occasionally	Often	Very Often
12. Runs about or climbs too much when remaining seated is expected.	Never	Occasionally	Often	Very Often
13. Has difficulty playing or beginning quiet play activities.	Never	Occasionally	Often	Very Often
14. Is “on the go” or often acts as if “driven by a motor”.	Never	Occasionally	Often	Very Often
15. Talks too much.	Never	Occasionally	Often	Very Often
16. Blurts out answers before questions have been completed.	Never	Occasionally	Often	Very Often
17. Has difficulty waiting his or her turn.	Never	Occasionally	Often	Very Often
18. Interrupts or intrudes in on others’ conversations and/or activities	Never	Occasionally	Often	Very Often

	Never	Occasionally	Often	Very Often
19. Argues with adults.	Never	Occasionally	Often	Very Often
20. Loses temper.	Never	Occasionally	Often	Very Often
21. Actively defies or refuses to go along with adults’ requests or rules.	Never	Occasionally	Often	Very Often
22. Deliberately annoys people.	Never	Occasionally	Often	Very Often
23. Blames others for his or her mistakes or misbehaviors.	Never	Occasionally	Often	Very Often
24. Is touchy or easily annoyed by others.	Never	Occasionally	Often	Very Often
25. Is angry or resentful.	Never	Occasionally	Often	Very Often
26. Is spiteful and wants to get even.	Never	Occasionally	Often	Very Often

	Never	Occasionally	Often	Very Often
27. Bullies, threatens, or intimidates others.	Never	Occasionally	Often	Very Often
28. Starts physical fights.	Never	Occasionally	Often	Very Often
29. Lies to get out of trouble or to avoid obligations (ie, “cons” others).	Never	Occasionally	Often	Very Often
30. Is truant from school (skips school) without permission.	Never	Occasionally	Often	Very Often
31. Is physically cruel to people.	Never	Occasionally	Often	Very Often
32. Has stolen things that have value.	Never	Occasionally	Often	Very Often
33. Deliberately destroys others’ property.	Never	Occasionally	Often	Very Often
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun).	Never	Occasionally	Often	Very Often
35. Is physically cruel to animals.	Never	Occasionally	Often	Very Often
36. Has deliberately set fires to cause damage.	Never	Occasionally	Often	Very Often
37. Has broken into someone else’s home, business, or car.	Never	Occasionally	Often	Very Often
38. Has stayed out at night without permission.	Never	Occasionally	Often	Very Often
39. Has run away from home overnight.	Never	Occasionally	Often	Very Often
40. Has forced someone into sexual activity.	Never	Occasionally	Often	Very Often

	Never	Occasionally	Often	Very Often
41. Is fearful, anxious, or worried.	Never	Occasionally	Often	Very Often
42. Is afraid to try new things for fear of making mistakes.	Never	Occasionally	Often	Very Often
43. Feels worthless or inferior.	Never	Occasionally	Often	Very Often
44. Blames self for problems, feels guilty.	Never	Occasionally	Often	Very Often
45. Feels lonely, unwanted, or unloved; complains that “no one loves him or her”.	Never	Occasionally	Often	Very Often
46. Is sad, unhappy, or depressed.	Never	Occasionally	Often	Very Often
47. Is self-conscious or easily embarrassed.	Never	Occasionally	Often	Very Often

Performance

	Excellent	Above Average	Average	Somewhat of a problem	Problematic
48. Overall school performance.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
49. Reading.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
50. Writing.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
51. Mathematics.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
52. Relationship with parents.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
53. Relationship with siblings.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
54. Relationship with peers.	Excellent	Above Average	Average	Somewhat of a problem	Problematic
55. Participation in organized activities (eg, teams)	Excellent	Above Average	Average	Somewhat of a problem	Problematic

Comments

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Form by NICHQ
National Inititative for Children's Healthcare Quality (2002).

Thank you for your time and information. The information will be securely sent to the Associated Therapists Office and will be forwarded to the appropriate doctor, nurse or therapist.

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