VANDERBILT ADHD RATINGS

Date of review: [Date]
Child: [Name or ID; age and school grade]
Reason: [First ADHD evaluation, medication follow-up, or a concern raised by school or family]
Edition: [First edition 2002 or third edition 2019; initial or follow-up forms]

WHO COMPLETED WHICH FORM
Parent form: [Who filled it in, their relationship to the child, and the date returned]
Teacher form: [Teacher's name and subject, and how many weeks or months they have known the child]
Other raters: [Second parent, another teacher, a coach, or none]
Medication during the rating period: [On medication, off medication, or not sure, for each form]

SYMPTOM COUNTS
Inattentive: [Parent count of 9 and teacher count of 9, items rated often or very often]
Hyperactive-impulsive: [Parent count of 9 and teacher count of 9]
Tracking figures: [Mean rating 0 to 3 for each domain on each form, or total symptom score 0 to 54]

PERFORMANCE
Parent ratings at 4 or 5: [Which areas: schoolwork, reading, writing, math, family, friends, activities; or none]
Teacher ratings at 4 or 5: [Which areas: reading, writing, math, classroom behavior, peers; or none]
Impairment: [Rule met or not met, on which form]

CO-OCCURRING SCREENS
Oppositional and conduct: [Positive or negative on each form]
Anxiety and depression: [Positive or negative on each form]
Learning: [Any teacher academic rating of 5, or none]

SIDE EFFECTS
Reported: [Follow-up forms only: each side effect and its severity, or none]
Growth and vitals: [Weight, height, heart rate, blood pressure, and change since the last visit]

PARENT AND TEACHER AGREEMENT
Agree on: [Domains and behaviors both raters report]
Differ on: [Where the forms differ and the likely reason, such as structure at school or homework at home]

IMPRESSION
Criteria: [Inattentive, hyperactive-impulsive, or combined presentation met; or not met]
History: [Symptoms before age 12, settings, impairment, and other causes considered]

PLAN
Treatment: [Medication and dose, parent training, behavior plan, or watch and repeat]
School: [Classroom supports, learning assessment, or education plan requested]
Next forms: [When the parent and teacher follow-up forms are due]

Clinician: [Name, credentials]