Form 407 - Initial Adhd Evaluation Parent Questionnaire Page 2
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4Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
III. SOCIAL / FAMILY HISTORY
This section to be completed by Parents
Mother’s name____________________________________________Father’s name____________________________________
Occupation_______________________________________________Occupation______________________________________
Parents: Married________
Divorced________
Separated________
Patient lives with:_________________________________________________________________________________________
Siblings – names and ages:__________________________________________________________________________________
_______________________________________________________________________________________________________
Is there a family history of Attention Deficit Disorder, depression or substance abuse?
Yes
No
If Yes please comment_____________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
IV. VANDERBILT ADHD DIAGNOSTIC PARENT RATING SCALE
This section to be completed by Parents
Please circle the frequency code which best describes your child in the context of what is appropriate for his/her age.
Frequency Code:
0 = Never
1 = Occasionally
2 = Often
3 = Very Often
1. Does not pay attention to details or makes careless mistakes, for example homework
0
1
2
3
2. Has difficulty sustaining attention to tasks or activities
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
(not due to oppositional behavior or failure to understand)
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
0
1
2
3
7. Loses thing necessary for tasks or activities (school assignments, pencils, or books)
0
1
2
3
8. Is easily 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 when 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/play activities quietly
0
1
2
3
14. Is “on the go” or often acts as if “driven by a motor”
0
1
2
3
Form 407 ADHD Parent Questionnaire
rev 3/08
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