Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Vanderbilt ADHD Assessment Screening
Your information
Child's Name
Date of Birth
____ / ____ / ________
Child's Age
Grade Level
Parent/Guardian Name
Difficulty sustaining attention
Does not seem to listen
Additional details
Easily distracted
Fidgets with hands or feet
Runs or climbs excessively
Talks excessively
Oppositional Behavior Items
Academic Performance Rating
Social Relationships Rating
Vanderbilt ADHD Assessment Screening template from formisoft.com. formisoft.com/intake-templates/vanderbilt-adhd-screening