NICHQ: Parent Informant (follow-up)


NICHQ Vanderbilt Assessment Follow-up—Parent Informant

Child’s Name:      Date of Birth:

Parent’s Name:      Parent’s Phone Number:

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:

Symptoms

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

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

19. Overall school performance

20. Reading

21. Writing

22. Mathematics

23. Relationship with parents

24. Relationship with siblings

25. Relationship with peers

26. Participation in organized activities (eg, teams)


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

Stomachache

Change of appetite—explain below

Trouble sleeping

Irritability in the late morning, late afternoon, or evening—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Socially withdrawn—decreased interaction with others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—explain below

Picking at skin or fingers, nail biting, lip or cheek chewing—explain below

Sees or hears things that aren’t there

Explain/Comments:

Leave this empty:

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Document name: NICHQ: Parent Informant (follow-up)
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April 14, 2022 8:06 am PDTNICHQ: Parent Informant (follow-up) Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
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