Parent Vanderbilt Questionnaire Vanderbilt for Parents Vanderbilt (for Parent) Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Date * (MM/DD/YYYY) Name * DOB * (MM/DD/YYYY) Parent Name(s) * Medication Checkbox On Medication Not on Medication Not Sure About Medication Phone Questions 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 on 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 direction, and fails to finish activities (not due to reusal 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 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. Run 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 ofen 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 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 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 (i.e., "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 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; comlains 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 48. Overall school performance Excellent Above Average Average Somewhat a Problem Problematic 49. Reading Excellent Above Average Average Somewhat a Problem Problematic 50 Writing Excellent Above Average Average Somewhat a Problem Problematic 51. Mathematics Excellent Above Average Average Somewhat a Problem Problematic 52. Relationship with parents Excellent Above Average Average Somewhat a Problem Problematic 53. Relationship with siblings Excellent Above Average Average Somewhat a Problem Problematic 54. Relationship with peers Excellent Above Average Average Somewhat a Problem Problematic 55. Participation in organized activities (e.g., teams) Excellent Above Average Average Somewhat a Problem Problematic If you are human, leave this field blank. Submit
