Symptoms Questionnaire for Parents

Transcription

1 Symptoms Questionnaire for Parents Name of Child: Date: Please answer all questions below about your child; the print the completed page to bring to the child s appointment. Click on the appropriate rating: Never Mild Often Severe. Poor attention to details. Careless mistakes in academic or other activities. Short attention span to tasks or play activities 4. Seems not to listen when spoken to 5. Difficulties following through and finishing tasks 6. Poor organization skills, procrastinates, takes a long time to start work 7. Avoids tasks requiring attention (homework, reading) 8. Loses and forgets things (school assignments, pencils, books) 9. Easily distracted (by external stimuli). Forgetful in daily activities. Fidgets hands or squirms in seat. Gets up from chair inappropriately (can't stay seated for a long time). Runs, climbs excessively, notably overactive 4. Difficulties playing quietly 5. Up and on the go (as if driven by a motor) 6. Talks excessively 7. Answers before question completed 8. Difficulties waiting turn 9. Interrupts or intrudes into conversation or activity. Eating difficulties. Sleeping difficulties. Headaches. Bed wetting 4. Speech delay (current or history of speech delay) 5. Abdominal pain or diarrhea 6. Anxiety (excessive fear) afraid of new situations 7. Depressed mood (unhappy child, cries easily, irritable) 8. Compulsive behavior (rituals, arranging objects, etc.) 9. Oppositional and defiant (refuses to cooperate, answers back, disobedient). Cruel. Social difficulties (mocked by other kids), likes to be on his own. Very "difficult" child. Mood swings 4. Feels easily hurt or cheated 5. Risk taking behaviors, hitting, throwing, runs to street, plays with fire 6. Tics, eye blinking, facial twitches 7. Spacing out, blank stare, in his own world 8. Destroys toys or property 9. Lies frequently 4. Picks on things (nails, clothing) 4. Wants to run things SBUHN Page of 6

2 Symptoms Questionnaire for Teachers Name of Child: Date: Please answer all questions below about your child; the print the completed page to bring to the child s appointment. Click on the appropriate rating: Never Mild Often Severe. Poor attention to details. Careless mistakes in academic or other activities. Short attention span to tasks or play activities 4. Seems not to listen when spoken to 5. Difficulties following through and finishing tasks 6. Poor organization skills, procrastinates, takes a long time to start work 7. Avoids tasks requiring attention (homework, reading) 8. Loses and forgets things (school assignments, pencils, books) 9. Easily distracted (by external stimuli). Forgetful in daily activities. Fidgets hands or squirms in seat. Gets up from chair inappropriately (can't stay seated for a long time). Runs, climbs excessively, notably overactive 4. Difficulties playing quietly 5. Up and on the go (as if driven by a motor) 6. Talks excessively 7. Answers before question completed 8. Difficulties waiting turn 9. Interrupts or intrudes into conversation or activity. Excessive demand for teacher's attention. Disrespectful behavior towards the teacher. Doesn't get along with other children.lacks leadership 4. Led by others 5. Picked on by other kids 6. Bullies other children 7. Fights with other children, displays violent behavior 8. Difficult child to have in class 9. Fails to complete homework and school assignments. Disturbs other children, interrupts the class. Childish, immature. Is the class clown. Easily frustrated in efforts 4. Takes too long to complete tasks 5. Significant learning problems, as reflected by grades SBUHN Page of 6

3 Stimulant Medication Checklist `ÜáäÇÛë=k~ãÉW= ==a~ów==== qìéëç~ó===== qüìêëç~ó qé~åüéê=`çãéäéíáåö=cçêãw= =jéçáå~íáçåw=kçk= ==k~ãéw= Directions: Beside each item below, indicate the degree of the problem with a checkmark (P ). Please respond to all items. Evaluate the child s behavior on the following days: Never Sometimes Ofter Very Often. Doesn t pay attention to details; makes careless mistakes. Difficulty paying attention. Does not seem to listen 4. Difficulty following instructions; does not finish things 5. Difficulty getting organized 6. Avoid doing things that require a lot of mental effort 7. Loses things 8. Easily distracted 9. Forgetful. Fidgets with hands or feet; squirms in seat. Difficulty remaining seated. Runs about or climbs on things. Difficulty playing quietly 4. On the go, acts as if driven by a motor 5. Talks excessively 6. Blurts out answers to questions 7. Difficulty awaiting turn 8. Interrupts others or butts into their activities 9. Loses temper. Argues with adults. Defies or refuses what you tell him/her to do. Does things to deliberately annoy others. Is touchy or easily annoyed by others 4. Is angry and resentful 5. Takes anger out on othes; tries to get even 6. Grabs things from other children 7. Throws things at other children 8. Smashes or destroys things 9. Gives dirty looks or makes threatening gestures to other children. Curses at or teases other children to provoke conflict. Damages other childrens property. Hits, pushes, or trips other children. Threatens to hurt other children 4. Engages in physical fights with other children SBUHN Page of 6

4 Stimulant Medication Checklist 5. Annoys other children to provoke them 6. Irratable 7. Unusually cheerful or happy 8. Sad, weepy, cries, or unhappy 9. Anxious 4. Spaced out, blank stares 4. Overly quiet 4. Lethargic, drowsy 4. Uninterested in others, stays by himself/herself 44. Difficulty falling asleep (parent) 45. Decreased appetite (parent) 46. Complains about headache, upset stomach, dizziness, and so forth 47. Tics, twitching, finger nail biting, unususal arm or leg movements 48. Unusually talkative 49. Other (please specify) Never Sometimes Ofter Very Often Comments: Please return both pages of this form to:, MD / NP Neurology; HSC T- SUNY Stony Brook, NY Or fax to (6) , ATTN:, MD / NP SBUHN Page 4 of 6

5 Vanderbilt ADHD Parent Rating Scale Today s Date: Child s Name: _ Date of Birth: Grade: Completed by: Relationship to child: Parent Other: _ 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? póãéíçãë================================================================================kéîéê=====låå~ëáçå~ääó=====lñíéå=====séêó=lñíéå. Does not pay attention to details or makes careless mistakes with, for example, homework. Has difficulty staying focused on what needs to be done. 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. Fidgets with hands or feet or squirms in seat. Leaves seat when remaining seated is expected. Runs about or climbs too much when remaining seated is expected. Has difficulty playing or beginning quiet play activities 4. Is on the go or often acts as if driven by a motor 5. Talks too much 6. Blurts out answers before questions have been completed 7. Has difficulty waiting his or her turn 8. Interrupts or intrudes in on others conversations and/or activities 9. Argues with adults. Loses temper. Actively defies or refuses to go along with adults requests or rules. Deliberately annoys people. Blames others for his or her mistakes or misbehaviors 4. Is touchy or easily annoyed by others 5. Is angry or resentful 6. Is spiteful and vindictive (wants to get even) 7. Bullies, threatens, or intimidates others 8. Starts physical fights 9. Lies to get out of trouble or to avoid obligations (i.e., cons others). Skips school without permission. Is physically cruel to people. Has stolen things that have value SBUHN4 Page of

6 Vanderbilt ADHD Parent Rating Scale Today s Date: Child s Name: _ Date of Birth: póãéíçãë================================================================================kéîéê=====låå~ëáçå~ääó=====lñíéå=====séêó=lñíéå. Deliberately destroys others property 4. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 5. Is physically cruel to animals 6. Has deliberately set fires to cause damage 7. Has broken into someone else s home, business, or car 8. Has stayed out at night without permission 9. Has run away from home overnight 4. Has forced someone into sexual activity 4. Is fearful, anxious, or worried 4. Is afraid to try new things for fear of making mistakes 4. Feels worthless or inferior 44. Blames self for problems, feels guilty 45. Feels lonely, unwanted, or unloved; complains that no one loves him/her 46. Is sad, unhappy, or depressed 47. Is self-conscious or easily embarrassed méêñçêã~ååé=============================================================================^äçîé=^îéê~öé==========^îéê~öé==========mêçääéã~íáå QUK=lîÉê~ää=~Å~ÇÉãáÅ=éÉêÑçêã~åÅÉ= N O P Q R a. Reading 4 5 b. Mathematics 4 5 c. Written expression Overall Classroom Behavior N O P Q R `çããéåíëw a. Relationship with peers 4 5 b. Following directions/rules 4 5 c. Disrupting class 4 5 d. Assignment completion 4 5 e. Organizational skills 4 5 cçê=lññáåé=rëé=låäów SYMPTOMS: Number of questions scored or in questions -9: Number of questions scored or in questions -8: Total symptom score for questions -8 (add all scores): Number of questions scored or in questions 9-6: Number of questions scored or in questions 7-4: Number of questions scored or in questions 4-47: PERFORMANCE: Number of items scored 4 or 5 in questions 48-49: Average performance score (total all scores, then divide by ): SBUHN4 Page of