Woodinville Pediatrics
fax 425 488 4919
(425) 483 5437
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Mill Creek
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Vanderbilt Parent Follow Up
Please enable JavaScript in your browser to complete this form.
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
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
20. Reading
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
21. Writing
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
22. Mathematics
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
23. Relationship with parents
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
24. Relationship with siblings
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
25. Relationship with peers
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
26. Participation in organized activities (eg, teams)
Excellent
Above Average
Average
Somewhat of a Problem
Problematic
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
Name
Submit
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