Vanderbilt Parent Follow Up - Woodinville Pediatrics

Name and relationship to patient *

Telehealth appointment Provider *

Patient Name *

First

Last

Date of Birth *

Email *

1. Does not pay attention to details or makes careless mistakes with, for example, homework

Never
Occasionally
Often
Very Often

2. Has difficulty keeping attention to what needs to be done

Never
Occasionally
Often
Very Often

3. Does not seem to listen when spoken to directly

Never
Occasionally
Often
Very Often

4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)

Never
Occasionally
Often
Very Often

5. Has difficulty organizing tasks and activities

Never
Occasionally
Often
Very Often

6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort

Never
Occasionally
Often
Very Often

7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)

Never
Occasionally
Often
Very Often

8. Is easily distracted by noises or other stimuli

Never
Occasionally
Often
Very Often

9. Is forgetful in daily activities

Never
Occasionally
Often
Very Often

10. Fidgets with hands or feet or squirms in seat

Never
Occasionally
Often
Very Often

11. Leaves seat when remaining seated is expected

Never
Occasionally
Often
Very Often

12. Runs about or climbs too much when remaining seated is expected

Never
Occasionally
Often
Very Often

13. Has difficulty playing or beginning quiet play activities

Never
Occasionally
Often
Very Often

14. Is “on the go” or often acts as if “driven by a motor”

Never
Occasionally
Often
Very Often

16. Blurts out answers before questions have been completed

Never
Occasionally
Often
Very Often

17. Has difficulty waiting his or her turn

Never
Occasionally
Often
Very Often

18. Interrupts or intrudes in on others’ conversations and/or activities

Never
Occasionally
Often
Very Often

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)

Side Effects: Has your child experienced any of the following side effects or problems in the past week? Are these side effects currently a problem? If yes, please answer questions below, if no, can skip questions below.

Yes
No

Headache

None
Mild
Moderate
Severe

Stomachache

None
Mild
Moderate
Severe

Change of appetite—explain below

None
Mild
Moderate
Severe

Trouble sleeping

None
Mild
Moderate
Severe

Irritability in the late morning, late afternoon, or evening—explain below

None
Mild
Moderate
Severe

Socially withdrawn—decreased interaction with others

None
Mild
Moderate
Severe

Extreme sadness or unusual crying

None
Mild
Moderate
Severe

Dull, tired, listless behavior

None
Mild
Moderate
Severe

Tremors/feeling shaky

None
Mild
Moderate
Severe

Repetitive movements, tics, jerking, twitching, eye blinking—explain below

None
Mild
Moderate
Severe

Picking at skin or fingers, nail biting, lip or cheek chewing—explain below

None
Mild
Moderate
Severe

Sees or hears things that aren’t there

None
Mild
Moderate
Severe

Explain/Comments