NICHQ Vanderbilt 评估量表----父母问卷

日期：--------------------患者姓名-----------------出生日期-----------------------------------------------

父母姓名------------------------------------------父母联系电话----------------------------------------------

提示：在评估时要审慎，应鉴别是否为与年龄相符的正常现象。在填写此表格时，请仔细回顾你的孩子过去６个月的行为举止。

此评估建立于当你的孩子　　――用药期间　　　――非用药期间　　――不肯定

1.不能仔细注意细节或常发生粗心大意所致的错误  0        1       2         3

2在学习工作或活动时，注意力难以持久          0        1       2         3                    

3.与之对话时,心不在焉,似听非听                 0        1       2         3               

4.不听从指令而难以完成各项工作和任务          0        1       2         3                                    

 (并非因为不理解教导)                                                                    

5.难以完成或组织各项工作和活动                0        1       2         3                                       

6.逃避、不喜欢或不愿参加那些需要精力          0        1       2         3                                     

  持久的工作或活动                                                                             

7 遗失作业或活动所需要的东西,如玩具，作业本， 0        1       2         3                                           

  铅笔或课本                                                                                

8.易因声音或其它外界刺激而分心                0        1       2         3                                                   

9.遗忘日常活动                                0        1       2         3                                                   

10.手或足有很多小动作，或在座位扭动           0        1       2         3                                                   

11在要求安坐的场合擅自离开座位               0        1       2         3                                                  

12.在要求坐好的场合奔来奔去或爬上爬下         0        1       2         3                                                   

13.不能安静地参加游戏或活动                   0        1       2         3                                                       

14.似被发动机驱动地一刻不停地活动             0        1       2         3                                                     

15.讲话过多                                   0        1       2         3                                                    

16.在他人问题还没问完时就急于回答             0        1       2         3                                                  

17.难以静侯轮换                               0        1       2         3                                                  

18.在他人交谈时插嘴或打断他人的活动           0        1       2         3                                               

19.与成人争论                                 0        1       2         3                                                    

20.发脾气                                     0        1       2         3                                                

21.经常拒绝大人的要求或不听规劝               0        1       2         3                                                     

22故意激怒他人                               0        1       2         3                                                    

23.把自己的过错或无礼归咎于他人               0        1       2         3                                                   

24.易被他人激怒或烦扰                         0        1       2         3                                                   

25.生气或愤恨                                 0        1       2         3                                                       

26.不屑一顾或冷漠                             0        1       2         3                                                      

27.恃强凌辱弱，威胁或恐吓他人                 0        1       2         3

  (如：坑别人)                                                  

28.攻击行为                                                          0         1       2         3                                      

29.为脱离烦恼或逃避责任而说谎                 0        1       2         3                                                    

30.未经批准逃学                               0        1       2         3                                                      

31.对人残忍                                   0        1       2         3                                                

48.总体成绩                      1        2           3          4        5                                                                                                   

49.阅读                          1        2           3          4        5                   

50.写作                          1        2           3          4        5                   

51.数学                          1        2           3          4        5                 

52.与父母关系                    1        2           3          4        5                 

53.与兄弟姐妹关系                1        2           3          4        5                     

54.与同学关系                    1        2           3          4        5                       

55.参加集体活动(如:团队)          1        2           3          4        5      

以下为工作人员所填

问题1－9中得分为2或3共几项:-----------------------------------------------------------------

问题10－18中得分为2或3共几项:--------------------------------------------------------------

问题1－18中共有几项阳性症状-------------------------------------------------------------------

问题19－26中得分为2或3共几项:--------------------------------------------------------------

问题27－40中得分为2或3共几项:--------------------------------------------------------------

问题41－47中得分为2或3共几项:--------------------------------------------------------------

问题48－55中得分为4或5共几项:--------------------------------------------------------------