Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
I. EDUCATION HISTORY This section to be completed by Parents
School______________________________________________________________________Current Grade________________
Primary Teacher____________________________________________________Total # of Teachers______________________
What grade did school problems start?________________________________________________________________________
Is your child currently receiving additional help?
Has your child had educational testing?
SSD________________ Other_____________________________________
No____ Yes____ If yes, by whom?_________________________________________
Results of testing_________________________________________________________________________________________
Other problems___________________________________________________________________________________________
_______________________________________________________________________________________________________
Areas of concern:
___absenteeism
___peer relations
___memory
___written expression
___classwork completion
___anger control
___risk taking
___motor skills
___attention
___homework
___disobedience
___self esteem
___reading
___distractibility
___health problems
___disruptive behavior
___unhappy @ school
___receptive language
___hyperactivity
___immaturity
___expressive language
___retaining information
___motivation
___math
___spelling
___inconsistent performance
___test taking
Comments on items __________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
II. PAST MEDICAL HISTORY / REVIEW OF SYSTEMS This section to be completed by Parents
Y N
Y N
1. Does the patient have any ongoing medical problems?
5. Did the mother have any medical problems during
pregnancy, labor, delivery or post delivery period?
2. Do you have concerns about diet, sleep, exercise?
6. Did the patient have difficulty breathing or crying
after delivery, have poor color, poor suck, slow
growth and development?
3. Has the patient had any of the following conditions:
surgical procedures, significant allergies or allergic
reactions to medications, head injury, seizures, facial
tics or other repeated body movements, meningitis
encephalitis or poisoning of any type?
7. Is the patient taking any medication at present?
If yes, list medications:
4. Has the patient had any of the following problems:
bed wetting, stool soiling, temper outbursts, mood
changes, anxiety, depression, getting along with
peers, lying, stealing, fire setting, destructiveness,
cruelty to animals or self injury?
8. Has your child been evaluated by an MD or mental
health professional in the past for school or
attentional problems?
If Yes to any of the above please comment_____________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Form 407 ADHD Parent Questionnaire
rev 3/08
Initial 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
Mothers name____________________________________________Fathers 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
2. Has difficulty sustaining attention to tasks or activities
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and fails to finish schoolwork
(not due to oppositional behavior or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
7. Loses thing necessary for tasks or activities (school assignments, pencils, or books)
8. Is easily distracted by extraneous 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 excessively in situations in which remaining seated is expected
13. Has difficulty playing or engaging in leisure/play activities quietly
14. Is on the go or often acts as if driven by a motor
Form 407 ADHD Parent Questionnaire
rev 3/08
Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his/her turn
18. Interrupts or intrudes on others (e.g., butts into conversations or games)
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to comply with adults requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or resentful
26. Is spiteful and vindictive
27. Bullies, threatens, or intimidates others
28. Initiates physical fights
29. Lies to obtain goods for favors or to avoid obligations (i.e.cons others)
30. Is truant from school (skips school) without permission
31. Is physically cruel to people
32. Has stolen items of nontrivial value
33. Deliberately destroys others property
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35. Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone elses home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved: complains that no one loves him/her
46. Is sad, unhappy, or depressed
47. Is self-conscious or easily embarrassed
Form 407 ADHD Parent Questionnaire
rev 3/08
Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
PERFORMANCE
Problematic
1. Overall Academic Performance
Average
Above Average
a. Reading
b. Mathematics
c. Written Expression
a. Relationship with Peers
b. Following Directions/Rules
c. Disrupting Class
d. Assignment Completion
e. Organizational Skills
2. Overall Classroom Performance
Please include any observations you feel are pertinent:__________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Return form to your pediatrician when complete.
Form 407 ADHD Parent Questionnaire
rev 3/08
