1

PARENT PACKET

Dear Parent or Guardian,

Thank you for your interest in having your child evaluated for Attention-Deficit/Hyperactivity Disorder (ADHD).

Please keep the following in mind when completing the packet of information:

• Parents and teachers should complete the questionnaires independently. Each on-line questionnaire MUST have a
completed NICHQ Vanderbilt form, one for each parent and one for each teacher (teens must have two teachers).
For youths completing on-line forms a SNAP-IV must also be completed.

• Any copies of educational testing, report cards, standardized tests, and other educational materials should be
returned with the packet or sent electronically via KP.org.

• Please do not skip any questions or answer items between responses.

• Make sure pages of the forms are not bent, folded, or stapled (and advise teachers to do the same)

Please complete the following items:

Parent and teacher paper /electronic questionnaires: Teacher forms should be completed by a teacher who has
known your child for at least three months and has observed him/her in a classroom setting (not distance learning).

• Completed packets should be placed in an envelope and returned to the Pediatrics clinic or sent
back as an attachment through the kp.org secure email system

Once the completed packet has been received and scored you will be contacted to schedule
an appointment for your child.

If you have any questions, please feel free to contact:

Stockton/Tracy: Noelia Munguia-Ramirez 209-476-5862

Modesto/Manteca: Maria Bouligny 209-557-1647
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ADHD EVALUATION HISTORY

Has your child ever been diagnosed by a professional as having “ADHD”, "Hyperactivity" or “Attention Deficit Disorder?”

No Yes

If so, at what age was the diagnosis made? By Whom:

Has your child received (or is your child currently receiving) medication for “ADHD”, "Hyperactivity" or "Attention Deficit
Disorder"?
No Yes

If so, please fill in the appropriate responses in the following chart:

Name of Medicine Dosage No. of Times Given Ages the Medicine

Each Day was Used

CHILD DEVELOPMENTAL HISTORY Yes No Unsure

Was any part of your child's development delayed?
Was any part of large muscle development (gross motor)
delayed? (Examples: sitting, walking, skipping, riding bicycle, etc.)
Was any part of the small muscle development (fine motor)
delayed? (Examples: drawing, writing, cutting, eating with utensils)
Was any part of the language development delayed?
(Examples: first words, 3-word phrases, pronunciation)

List ages for the following for your AGE DO NOT RECALL
child:
Walked without holding on
Said 3 single words
Made 3-word sentences

Which hand does your child prefer to use? Left or Right

How old was your child when you noticed which hand, he/she preferred?
 NEURODEVELOPMENTAL SKILLS

Please rate your child as he or she compares with other children his or her own age. Please check the appropriate box.

Specific Skills Better Average Worse

Catching and throwing a ball
Running
Building things (e.g., models, Legos)
Drawing/Art
Writing
Understanding spoken directions (understanding what you
want him/her to do)
Speaking clearly
Describing things
Ability to remember things

SCHOOL HISTORY

In the table below, please check Yes for areas that your child has had difficulty and list the school grade(s) when the problems
occurred.

School History Yes Grade(s)

Your child has had speech or language problems
Your child was diagnosed with a learning disorder? Please list the grade when the diagnosis
occurred.
Your child was (is) in Special Day Class?
Your child was (is) in Resource Class?
Your child has had reading problems?
Your child has had writing problems?
Your child has had spelling problems?
Your child has had math problems?
Your child has had other problems? Please specify:

List all schools your child has attended from preschool(s) to the present. Include the name of the school district
for each California school your child has attended.

School Name District Name Grade(s) Dates (years)

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SCHOOL PERFORMANCE AND BEHAVIORS

Have your child’s teachers described any of the following as significant problems?

(For each that apply, please specify grades in which problem(s) occurred)

From Grade To Grade

Very changeable in academic performance over course of the day or week

Very changeable in behavior over course of day or week

Doesn’t sit still in his/her seat

Frequently gets up and walks around the classroom

Shouts out. Doesn’t wait to be called on

Difficulty waiting for his/her turn

Often talks excessively; difficulty playing quietly

Doesn’t respect the rights of others

Doesn’t cooperate well in group activities

Behavior problems worsen during free time (e.g., lunch, recess, etc.)

Inattentive, trouble focusing, easily distracted (e.g., often “off task,” makes
careless mistakes, etc.)

Difficulty organizing or fails to finish classwork or homework

Loses school materials, e.g., books, pencils, homework assignments,

homework, etc.

Describe any other classroom performance and/or behavior problem

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SOCIAL BEHAVIORS

Please read the following questions carefully and mark the appropriate answer.

Office Use
Behaviors Yes No
Only
1. Does s/he join in playing games with other children easily?
2. Does s/he come up to you spontaneously for a chat?
3. Was s/he speaking by 2 years old?
4. Does s/he enjoy sports?
5. Is it important to him/her to fit in with the peer group?
6. Does s/he appear to notice unusual details that others miss?
7. Does s/he tend to take things literally?
8. When s/he was 3 years old, did s/he spend a lot of time pretending (e.g., play-
acting being a superhero, or holding teddy’s tea parties)?
9. Does s/he like to do things over and over again, in the same way all the time?
10. Does s/he find it easy to interact with other children?
11. Can s/he keep a two-way conversation going?
12. Can s/he read appropriately for his/her age?
13. Does s/he mostly have the same interests as his/her peers?
14. Does s/he have an interest which takes up so much time that s/he does little
else?
15. Does s/he have friends, rather than just acquaintances?
16. Does s/he often bring you things s/he is interested in to show you?
17. Does s/he enjoy joking around?
18. Does s/he have difficulty understanding the rules for polite behavior?
19. Does s/he appear to have an unusual memory for details?
20. Is his/her voice unusual (e.g., overly adult, flat, or very monotonous)?
21. Are people important to him/her?
22. Can s/he dress him/herself?
23. Is s/he good at turn-taking in conversation?
24. Does s/he play imaginatively with other children, and engage in role-play?
25. Does s/he often do or say things that are tactless or socially inappropriate?
26. Can s/he count to 50 without leaving out any numbers?
27. Does s/he make normal eye-contact?
28. Does s/he have any unusual and repetitive movements?
29. Is his/her social behavior very one-sided and always on his/her own terms?
30. Does s/he sometimes say “you” or “s/he” when s/he means “I”?
31. Does s/he prefer imaginative activities such as play-acting or storytelling, rather
than numbers or lists of facts?
32. Does s/he sometimes lose the listener because of not explaining what s/he is
talking about?
33. Can s/he ride a bicycle (even if with stabilizers)?
34. Does s/he try to impose routines on him/her, or on others, in such a way that it
causes problems?
35. Does s/he care how s/he is perceived by the rest of the group?
36. Does s/he often turn conversations to his/her favorite subject rather than
following what the other person wants to talk about?
37. Does s/he have odd or unusual phrases?
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SPECIAL NEEDS SECTION

Please read the following questions carefully and mark the appropriate answer.

Behaviors Yes No

38. Have teachers/classroom visitors ever expressed any concerns about his/her
development?
39. Has s/he ever been diagnosed with any of the following?
Language delay
Hyperactivity/Attention Deficit Disorder (ADHD)
Hearing or visual difficulties
Autism Spectrum Disorder
A physical disability
Other (please specify):

For Office Use ONLY: Total for CAST Score _____ significant > 15
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HOME BEHAVIORS

All children, to some degree, exhibit the behaviors listed below. In the following chart, check those behaviors that you believe
your child has exhibited to an excessive or exaggerated degree when compared to other children his or her own age. For each
problem behavior, specify between what ages it has been a problem.

Home Behaviors Yes Ages

Poor attention span? (problems concentrating)
Impulsive behavior? (poor self-control)
Temper outbursts?
Low frustration tolerance? (easily frustrated)
Interrupts frequently? (butts in while others are talking)
Doesn't listen?
Outbursts of physical abuse toward other children?
Acts like he or she is driven by a motor?
Heedless to danger?
Excessive number of accidents?
Doesn't learn from experience?
Poor memory?
More active than siblings?
Excessive fearfulness?
Fire-setting?
Vandalism?
Stealing?
Trouble staying focused; easily distracted
Often doesn’t seem to listen when spoken to directly
Often forgetful in daily activities
Trouble finishing things; often darts from one activity to
another
Difficulty with organization, e.g., completing chores, etc.
Easily bored
Often loses things, e.g., toys, school assignments,
tools, etc.
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STRESSORS

Please list any unusual and/or traumatic family event(s) in your child's life that you feel may have impacted upon his
or her development and current problems (e.g., birth of a sibling, any death in the family, divorce, illnesses, frequent
school changes, family moves, etc.

Incident: Child's Age: Comments:

Please include any additional comments regarding your child's difficulties as well as his or her strengths

Name: Phone number: Date:

Thank you for your time and effort in completing this questionnaire