Children Specialty Care Clinic

□ A. Haseeb, M.D. □ S. Tahir, M.D. □ R. Abbas, M.D. □ S. Umair, M.D. □ V. Richard, FNP-C □ T. Kaplinger, P.A.
□ A. Miller, P.A. □ A. Sanders, P.A. □ C. Fincher, FNP-C □ P. Porter, FNP-C □ S. Clay, P.A. □ D. Williams, RN-CPNP

NICHQ Vanderbilt Assessment Follow-up—PARENT Informant

* indicates required fields

Step 1 completion: 0%

Today's Date *

Child's Name *

Date of Birth *

Parent's Name *

Parent's Phone Number *

Directions: Each rating should be considered in the context of what is appropriate for the age of your child. Please think about your child's behaviors in the past __ when rating his/her behaviors.

Is this evaluation based on a time when the child: *

was on medicationwas not on medicationnot sure

Symptoms *

Symptoms	Never	Occasionally	Often	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

Performance *

Performance	Excellent	Above Average	Average	Somewhat of a Problem	Problematic
19. Overall school performance
20. Reading
21. Writing
22. Mathematics
23. Relationship with parents
24. Relationship with siblings
25. Relationship with peers
26. Participation in organized activities (eg. teams)

Practice Manager

Crystal Miranda

31303 FM 2920 STE G
Waller, TX 77484

Call: 936-931-3448
Fax: 936-931-3704

Billing

Murtaza Tahir

1223 Fry Street
Waller, TX 77484

Call: 936-931-3448
Fax: 936-372-3968

Clinic Info

Waller Fax: 936-931-3704

Magnolia Fax: 281-252-0644

Cypress Fax: 281-304-7786

Katy Fax: 281-600-0787