Screening

Vanderbilt ADHD Assessment Screening

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Vanderbilt ADHD Assessment Screening

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Child's Name
Jane Martinez
Date of Birth
03/15/1985
Child's Age
0
Grade Level
Select an option...
Parent/Guardian Name
Jane Martinez
Difficulty sustaining attention
Option A
Option B
Option C
Does not seem to listen
Option A
Option B
Option C
Easily distracted
Option A
Option B
Option C
Fidgets with hands or feet
Option A
Option B
Option C
Runs or climbs excessively
Option A
Option B
Option C
Talks excessively
Option A
Option B
Option C
Oppositional Behavior Items
Option A
Option B
Option C
Academic Performance Rating
Select an option...
Social Relationships Rating
Select relationship...
Submit
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The Vanderbilt ADHD Assessment Screening form digitizes the Vanderbilt ADHD Diagnostic Rating Scale, one of the most widely used tools for the initial evaluation of ADHD in school-age children. Developed at Vanderbilt University, this parent-completed assessment aligns directly with DSM-5 diagnostic criteria and evaluates not only core ADHD symptoms but also common comorbid conditions including oppositional defiant disorder, conduct disorder, and anxiety/depression.

The questionnaire presents behavioral statements that parents rate on a 0-3 frequency scale (never, occasionally, often, very often). The inattention section covers nine items such as difficulty sustaining attention, not listening when spoken to, losing things, and being easily distracted. The hyperactivity-impulsivity section covers nine items including fidgeting, leaving seat, running or climbing, talking excessively, and difficulty waiting turns. Additional sections screen for oppositional and conduct behaviors, anxiety and depression symptoms, and academic/social performance impairment.

This template is designed for pediatric primary care practices conducting ADHD evaluations, child psychiatry and developmental-behavioral pediatrics clinics, school-based assessment teams, and family medicine practices. The Vanderbilt Assessment is recommended by the American Academy of Pediatrics as part of the comprehensive ADHD evaluation process and is freely available for clinical use. A companion teacher rating form can be used alongside this parent form to gather multi-informant data, which is required for an accurate ADHD diagnosis per AAP guidelines.

What's included

  • Nine DSM-5 inattention symptom items
  • Nine DSM-5 hyperactivity-impulsivity symptom items
  • Oppositional defiant and conduct disorder screening
  • Anxiety and depression comorbidity screening
  • Academic and social performance impairment assessment
  • Parent-reported frequency rating scales

Who uses this template

  • Pediatric primary care ADHD evaluation and diagnosis
  • Child psychiatry and developmental-behavioral pediatrics intake
  • School-based ADHD assessment and IEP documentation
  • Family medicine ADHD screening for school-age children

All form fields

14 fields across 3 pages. Customize any field after signing up.

Child's NameText
Date of BirthDate
Child's AgeNumber
Grade LevelDropdown
Parent/Guardian NameText
Difficulty sustaining attentionMultiple Choice
Does not seem to listenMultiple Choice
Easily distractedMultiple Choice
Fidgets with hands or feetMultiple Choice
Runs or climbs excessivelyMultiple Choice
Talks excessivelyMultiple Choice
Oppositional Behavior ItemsMultiple Choice
Academic Performance RatingDropdown
Social Relationships RatingDropdown
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