This form contains 18 symptom items only. It is not a complete Vanderbilt assessment and cannot establish or exclude a diagnosis. A clinician must review the results. NICHQ Vanderbilt Assessment Scale Rating: 0 = Never | 1 = Occasionally | 2 = Often | 3 = Very Often Student Information Student's First Name Student's Last Name Student's Date of Birth Inattention Symptoms (Questions 1-9) 1. Fails to give attention to details or makes careless mistakes 0 - Never1 - Occasionally2 - Often3 - Very Often 2. Has difficulty sustaining attention 0 - Never1 - Occasionally2 - Often3 - Very Often 3. Does not seem to listen when spoken to directly 0 - Never1 - Occasionally2 - Often3 - Very Often 4. Does not follow through on instructions and fails to finish work 0 - Never1 - Occasionally2 - Often3 - Very Often 5. Has difficulty organizing tasks and activities 0 - Never1 - Occasionally2 - Often3 - Very Often 6. Avoids tasks requiring sustained mental effort 0 - Never1 - Occasionally2 - Often3 - Very Often 7. Loses things necessary for tasks or activities 0 - Never1 - Occasionally2 - Often3 - Very Often 8. Is easily distracted by extraneous stimuli 0 - Never1 - Occasionally2 - Often3 - Very Often 9. Is forgetful in daily activities 0 - Never1 - Occasionally2 - Often3 - Very Often Hyperactivity/Impulsivity Symptoms (Questions 10-18) 10. Fidgets with hands or feet or squirms in seat 0 - Never1 - Occasionally2 - Often3 - Very Often 11. Leaves seat when remaining seated is expected 0 - Never1 - Occasionally2 - Often3 - Very Often 12. Runs about or climbs excessively in inappropriate situations 0 - Never1 - Occasionally2 - Often3 - Very Often 13. Has difficulty playing or engaging in leisure activities quietly 0 - Never1 - Occasionally2 - Often3 - Very Often 14. Is "on the go" or acts as if "driven by a motor" 0 - Never1 - Occasionally2 - Often3 - Very Often 15. Talks excessively 0 - Never1 - Occasionally2 - Often3 - Very Often 16. Blurts out answers before questions have been completed 0 - Never1 - Occasionally2 - Often3 - Very Often 17. Has difficulty waiting their turn 0 - Never1 - Occasionally2 - Often3 - Very Often 18. Interrupts or intrudes on others 0 - Never1 - Occasionally2 - Often3 - Very Often Respondent Information Your Name Relationship to Student
