Vanderbilt Assessment Scale Tool - Excel Center Fort Worth Page 2

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36. Has deliberately set fires to cause damage
37. Has broken into someone else’s home, business or car
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38. Has stayed out at night without permission
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39. Has run away from home overnight
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40. Has forced someone into sexual activity
Total: Often/Very Often
Never
Occas-
Often
Very Often
Symptoms:
ionally
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41. Is fearful, anxious, or worried
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42. Is afraid to try new things for fear of making mistakes
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43. Feels worthless or inferior
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44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved: complains that “no one loves him or her”
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46. Is sad, unhappy, or depressed
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47. Is self-conscious or easily embarrassed
Total: Often/Very Often
Excellent
Above Average
Average
Somewhat of a
Problemati
Performance Academic Performance
problem
c
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48. Reading
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49. Mathematics
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50. Written Expression
Excellent
Above Average
Average
Somewhat of a
Problemati
Performance Classroom Behavior
problem
c
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51. Relationship with peers
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52. Following directions
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53. Disrupting class
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54. Assignment completion
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55. Organizational skills
COMMENTS:
FOR OFFICE USE ONLY:
Total Number of items scored 2 or 3 in items 1-9:
(ADHD, predominantly inattentive type = 6 + symptoms)
Total number of items scored 2 or 3 in items 10-18:
(ADHD, predominantly hyperactive type = 6 + symptoms)
Total Symptoms Score for items 1–18:
(ADHD, predominantly combined type-6 + symptoms of both)
Total number of items scored 2 or 3 in items 19-26:
(oppositional defiant disorder = 4 +
symptoms)
Total number of items scored 2 or 3 in items 27-40:
(conduct disorder = 3 + symptoms)
Total number of items scored 2 or 3 in items 41-47:
(anxiety/depression = 3 + symptoms)
PATIENT NAME:
VANDERBILT ASSESSMENT SCALE
PARENT INFORMANT #6175
Adapted from the Vanderbilt Rating Scale by Mark L Wolraich, MD

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