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1 Date: Child s Name: Date of Birth: Dear Parent: Because ADD/ADHD is a chronic condition requiring ongoing medication, it is our policy to follow your child every 6 months to monitor his or her progress and growth. Our records indicate that it has been 6 months or more since your child s last medication evaluation visit. Consequently, a new evaluation is required before a prescription can be refilled or issued. Enclosed please find questionnaires for you as well as your child s teacher(s) to complete. If your child is of middle school age or older, your child will need to complete two of the forms: (1) Adolescent Current Symptoms Scale and (2) Pediatric Symptom Checklist Youth. Please return the questionnaires to us. After the forms have been received and reviewed by the Provider, we will contact you to schedule an appointment for a medication evaluation. Please be aware, there are additional charges involved in the scoring and evaluation of these questionnaires. These charges will be added to the office visit charge on the date of the visit. Thank you for your cooperation. In the meantime, please do not hesitate to call, (720) , if you have questions regarding this process. We look forward to working with you. Sincerely, Enclosures ADD Specialist Please return this letter with the completed questionnaires. Thank you! For internal use only: Appointment: Packet reviewed by: Time spent in Review: Time Required for Appt: ADD072 Rev0514
2 FOLLOW-UP ADHD QUESTIONNAIRE FOR PARENTS Parent Name Date Completed Child s Name DOB: Time Completed am pm Name of medication (if any) (brand name or generic) Current dosage schedule: 1 st dose - mg at am pm (circle one) 2 nd dose- mg at am pm 3 rd dose - mg at am pm 1. What strengths does your child currently show at this time? 2. What changes have there been, if any, since the last time this report was completed? For the better: For worse: ADD073 Rev0514
3 Today's Date: CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION NICHQ Vanderbilt Assessment Follow-up: Parent Informant Child's Name: Child's Date of Birth: Parent's Name: Directions: Each rating should be considered in the context of what is appropriate for the age of your child. Is this evaluation based on a time when the child Symptoms Never Occationally Often Very Often 9 Is forgetful in daily activities & 3s: /9 18 Interrupts or intrudes in on others' conversations and/or activities & 3s: /9 26 Is spiteful and wants to get even Does not pay attention to details or makes careless mistakes with, for example, homework Has difficulty keeping attention to what needs to be done Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand) Has difficulty organizing tasks and activities Avoids, dislikes, or does not want to start tasks that require ongoing mental effort Loses things necessary for tasks or activities (toys, assignments, pencils, books) Is easily distracted by noises or other stimuli 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 Is "on the go" or often acts as if "driven by a motor" Talks too much Blurts out answers before questions have been completed Has difficulty waiting his or her turn 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 Is touchy or easily annoyed by others Is angry or resentful Bullies, thereatens, or intimidates others Starts physical fights Lies to get out of trouble or to avoid obligations (ie. "cons" others) 2 & 3s: /8 MONITORING AND FOLLOW-UP Page 1 of 2
4 CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION 40 Has forced someone into sexual activity Is truant from school (skips school) without permission Is physically cruel to people Has stolen things that have value Deliberately destroys others' property Has used a weapon that can cause serious harm (bat, knife, brick, gun) Is physically cruel to animals Has deliberately set fires to cause damage Has broken into someone's home, business, or car Has stayed out at night without permission Has run away from home overnight Is fearful, anxious, or worried Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved; complains "no one loves him/her" Is sad, unhappy, or depressed 2 & 3s: /14 47 Is self-concious or easily embarrassed Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Performance 48 Reading 2 & 3s: /7 49 Writing 4s: /3 50 Mathmatics 51 Relationship with parents 52 Relationship with siblings 5s: /3 53 Relationship with peers 4s: /4 54 Participation in organized activities (eg. teams) Side Effects - Has your child experienced any of the following side effects or problems in the past week? Headache Stomachache Change of Appetite - Explain Below Trouble Sleeping Irritability in the late morning, late afternoon, or evening - explain below Socially withdrawn - decreased interaction with others Extreme sadness or unusual crying Dull, tired, listless behavior Tremmors/feeling shaky Repetitive movements, tics, jerking, twitching, eye blinking - explain below Picking at skin or fingers, nail biting, lip or cheek chewing - explain below Sees or hears things that aren't there Excellent Above Average Average Somewhat of a Problem Problematic Are these side effects currently a problem? 5s: /4 None Mild Moderate Severe (Y/N) MONITORING AND FOLLOW-UP Page 2 of 2
5 Child s Name: Filled out by: Date of Birth: Today s Date: Pediatric Symptom Checklist 17 (PSC-17) Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child s behavior, emotions, or learning, you may help your child get the best care possible by answering these questions. Please indicate which statement best describes your child. Please mark under the heading that best describes your child: Never Sometimes Often Fidgety, unable to sit still Feels sad, unhappy Daydreams too much Refuses to share Does not understand other people s feelings Feels hopeless Has trouble concentrating Fights with other children Is down on him or her self Blames others for his or her troubles Seems to have less fun Does not listen to rules Acts as if driven by a motor Teases others Worries a lot Takes things that do not belong to him or her Distracted easily Total Total Total , M. Jellinek & J.M. Murphy, Massachusetts General Hospital 17-item version created by W. Gardner & K. Kelleher
6 Date: Child s Name: Date of Birth: Dear Teacher: Because ADD/ADHD is a chronic condition requiring ongoing medication, it is our policy to follow children on medication every 6 months to monitor their progress and growth. Please complete the enclosed questionnaires and return the questionnaires to the child s parent. If you have any questions regarding the questionnaires or this process, please do not hesitate to contact one of our ADD coordinators at Thank you for your cooperation. We look forward to working with you. Sincerely, ADD Coordinator Enclosures Please return this letter with the completed questionnaires. Thank you! For internal use only: Appointment: Packet reviewed by: Time spent in Review: Appt: Time Required for ADD154 Rev0514
7 FOLLOW-UP ADHD QUESTIONNAIRE FOR TEACHERS Child s Name Date Completed Teacher s Name Subject Taught 1. Did you complete an initial report on this child? No Yes If no, how long have you known this child? Daily average of hours with child: 2. What strengths does the child currently show at this time? 3. What changes have there been, if any, since the last time this report was completed? (Quantitative change in specific academic subjects, e.g., much worse, etc.) For the better: Subjects For worse: Subjects Thank you. Please give the completed form to the child s parent for return to our office. ADD075 Rev0514
8 CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION NICHQ Vanderbilt Assessment Follow-Up: Teacher Informant Today's Date: Child's Name: Date of Birth: Teacher's Name: Class Name: Period: Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child's behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors:. Symptoms Never Occationally Often Very Often 9 Is forgetful in daily activities & 3s: /9 18 Interrupts or intrudes in on others' conversations and/or activities Is angry or resentful 22 Is spiteful and vindictive 23 Bullies, threatens, or intimidates others Fails to give attention to details or makes careless mistakes in schoolwork. Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through when given directions and fails to finish schoolwork (not due to opositional behavior or failure to understand) Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities (school assignments, pencils, books) Is easily distracted by extraneous stimuli Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected. Runs about or climbs excessively in situations in which remaining seated is expected Has difficulty playing or engaging in leisure activities quietly Is "on the go" or often acts as if "driven by a motor" Talks excessively Blurts out answers before questions have been completed Has difficulty waiting in line (eg, butts into conversations/games) Loses temper Actively defies or refuses to go along with adults' requests or rules Initiates physical fights Lies to obtain goods for favors or to avoid obligations (ie. "cons" others) Is physically cruel to people Has stolen items of nontrivial value 2 & 3s: /9 28 Deliberately destroys others' property 2 & 3s: /10 MONITORING AND FOLLOW-UP Page 1 of 2
9 CARING FOR CHILDREN WITH A D H D : A RESOURCE TOOLKIT FOR CLINICIANS, 2ND EDITION Symptoms Is fearful, anxious, or worried Is self-concious or easily embarrassed Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems; feels guilty Feels lonely, unwanted, or unloved; complains "no one loves him/her" Never Occationally Often Very Often 35 Is sad, unhappy, or depressed Academic Performance 36 Reading Excellent Above Average Average Somewhat of a Problem Problematic 2 & 3s: /7 37 Mathmatics 4s: /3 38 Written expression Classroom Behavioral Performance 39 Relationship with peers 40 Following directions 41 Disrupting class 5s: /3 42 Assignment completion 4s: /5 43 Organizational skills Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD. Side Effects: Has the child experienced any of the following side effects or problems in the past week? Headache Stomachache Change of Appetite - Explain Below Trouble Sleeping Irritability in the late morning, late afternoon, or evening - explain below Socially withdrawn - decreased interaction with others Extreme sadness or unusual crying Dull, tired, listless behavior Tremmors/feeling shaky Repetitive movements, tics, jerking, twitching, eye blinking - explain below Picking at skin or fingers, nail biting, lip or cheek chewing - explain below Sees or hears things that aren't there Explain/Comments: Are these side effects currently a problem? 5s: /5 None Mild Moderate Severe (Y/N) Adapted from the Pittsburgh side effects scale, developed by William E. Palham, Jr, PhD. MONITORING AND FOLLOW-UP Page 2 of 2
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