Vanderbilt Assessment Scale Tool - Excel Center Fort Worth
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2Name: ____________________________________________ Gender: ______Age:_______ Grade: _______ Date: ___________
Completed by: __________________________________________ Phone #: ________________________ Date: ______________
Directions: Each rating should be considered in the context of what is appropriate for the age of your child. When completing
this form, please think about your child’s behaviors in the past 6 months. Is this evaluation based on a time when the child.
□ was on medication
□ was not on medication
□ not sure
Never
Occas-
Often
Very Often
Symptoms:
ionally
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1. Does not pay close attention to details or makes careless mistakes with(e.g., homework)
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2. Has difficulty keeping attention to what needs to be done
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3. Does not seem to listen when spoken to directly
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4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties
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5. Has difficulty organizing tasks and activities
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6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., Schoolwork or homework)
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7. Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
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8. Is distracted by extraneous stimuli
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9. Is forgetful in daily activities
TOTAL Often /Very Often
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10. Fidgets with hands or feet or squirms in seat
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11. Leaves seat in classroom or in other situations in which remaining seated is expected
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12. Runs about or climbs excessively in situations in which remaining seated is expected
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13. Has difficulty playing or engaging in leisure activities quietly
14. Is “on the go” or often acts as if “driven by a motor”
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15. Talks excessively
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16. Blurts out answers before questions have been completed
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17. Has difficulty awaiting turn
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18. Interrupts or intrudes on others (e.g., butts into conversations/games)
TOTAL Often /Very Often
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19. Argues with adults
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20. Loses temper
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21. Actively defies or refuses to go along with adult requests or rules
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22. Deliberately annoys people
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23. Blames others for his or her mistakes or misbehaviors
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24. Is touch or easily annoyed by others
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25. Is angry or resentful
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26. Is spiteful and wants to get even
TOTAL Often /Very Often
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27. Bullies, threatens, or intimidates others
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28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (e.g. “cons”others)
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30. Is truant from school (skips school) without permission
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31. Is physically cruel to people
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32. Has stolen things that have value
33. Deliberately destroys others’ property
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34. Has used a weapon that can cause damage
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35. Is physically cruel to animals
PATIENT NAME:
VANDERBILT ASSESSMENT SCALE
PARENT INFORMANT #6175
Adapted from the Vanderbilt Rating Scale by Mark L Wolraich, MD
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Parent category: Medical