Vanderbilt Form – Fill Out and Use This PDF

Enter Today's Date, Child's Name, Date of Birth, Parent's Name and Parent's Phone Number.

For each Symptoms row, mark one of Never, Occasionally, Often or Very Often.

1. Does not pay attention to details or makes careless mistakes with, for example, homework 2. Has difficulty keeping attention to what needs to be done 3. Does not seem to listen when spoken to directly 4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) 5. Has difficulty organizing tasks and activities 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort 7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books) 8. Is easily distracted by noises or other 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 too much when remaining seated is expected 13. Has difficulty playing or beginning quiet play activities 14. Is “on the go” or often acts as if “driven by a motor” 15. Talks too much 16. Blurts out answers before questions have been completed 17. Has difficulty waiting his or her turn 18. Interrupts or intrudes in on others' conversations and/or activities

19. Argues with adults 20. Loses temper 21. Actively defies or refuses to go along 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 wants to get even

27. Bullies, threatens, or intimidates others 28. Starts physical fights 29. Lies to get out of trouble 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 things that have 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

Mark Never, Occasionally, Often or Very Often in each row.

37. Has broken into someone else's 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 or her” 46. Is sad, unhappy, or depressed 47. Is self-conscious or easily embarrassed

For each Performance row, mark one of Excellent, “Above Average”, Average, Somewhat of a Problem or Problematic.

48. Overall school performance 49. Reading 50. Writing 51. Mathematics 52. Relationship with parents 53. Relationship with siblings 54. Relationship with peers 55. Participation in organized activities (e.g. teams)

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