Child Behavior Follow-Up Assessment

Today's Date

Child's Name

First Last

Child's 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

was on medication
was not on medication
not sure?

Symptoms

1. Does not pay attention to details or makes careless mistakes with, for example, homework.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

2. Has difficulty keeping attention to what needs to be done.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

3. Does not seem to listen when spoken to directly.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand).

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

5. Has difficulty organizing tasks and activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books).

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

8. Is easily distracted by noises or other stimuli.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

9. Is forgetful in daily activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

10. Fidgets with hands or feet or squirms in seat.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

11. Leaves seat when remaining seated is expected.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

12. Runs about or climbs too much when remaining seated is expected.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

13. Has difficulty playing or beginning quiet play activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

14. Is “on the go” or often acts as if “driven by a motor”.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

15. Talks too much.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

16. Blurts out answers before questions have been completed.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

17. Has difficulty waiting his or her turn.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

18. Interrupts or intrudes in on others’ conversations and/or activities.

Never - 0
Occasionally - 1
Often - 2
Very Often - 3

Performance

19. Overall school performance

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

20. Reading

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

21. Writing

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

22. Mathematics

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

23. Relationship with parents

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

24. Relationship with siblings

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

25. Relationship with peers

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

26. Participation in organized activities (eg, teams)

Excellent - 1
Above Average - 2
Average - 3
Somewhat of a Problem - 4
Problematic - 5

The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD. Revised - 0303