1
Connors Parent Questionnaire
Name of Child: ____________________________________________________________ DOB: _____________
Name of Parent Completing Form: _______________________________________________________________
Please answer all questions. Beside each item below, indicate the degree of the problem by a check mark.
Not at
all.
Just a
little.
Pretty
much.
Very
much.
1. Picks at things (nails, fingers, hair, clothing).
2. Sassy to grown-ups.
3. Problems with making or keeping friends.
4. Excitable, impulsive.
5. Wants to run things.
6. Sucks or chews (thumb, clothing, blankets).
7. Cries easily or often.
8. Carries a chip on his shoulder.
9. Daydreams.
10. Difficulty in learning.
11. Restless in the “squirmy” sense.
12. Fearful (of new situations, new people or places,
school).
13. Restless, always up and on the go.
14. Destructive.
15. Tells lies or stories that are not true.
16. Shy.
17. Gets into more trouble than others of the same age.
18. Speaks differently from others of the same age (baby
talk, stuttering, hard to understand).
19. Denies mistakes, or blames others.
20. Quarrelsome.
21. Puts and sulks.
22. Steals.
23. Disobedient or obeys but resentfully.
24. Worries more than others (about being alone; illness or
death).
25. Fails to finish things.
26. Feelings easily hurt.
27. Bullies others.
28. Unable to stop a repetitive activity.
29. Cruel.
30. Childish or immature (wants help he shouldn’t need,
clings, needs constant reassurance).
South East Bay Pediatrics (12/04)
2
31. Distractibility or attention span a problem.
32. Headaches
33. Mood changes quickly and drastically.
34. Doesn’t like or doesn’t follow restrictions.
35. Fights constantly.
36. Doesn’t get along well with brothers or sisters.
37. Easily frustrated in efforts.
38. Disturbs other children.
39. Basically an unhappy child.
40. Problems with eating (poor appetite, up between bites).
41. Stomach aches.
42. Problems with sleep (can’t fall asleep, up too early, up
at night).
43. Other aches and pains.
44. Vomiting or nausea.
45. Feels cheated in family circle.
46. Boasts and brags.
47. Lets self be pushed around.
48. Bowel problems (frequently loose, irregular habits,
constipation).
South East Bay Pediatrics (12/04)
3
Vanderbilt Parent Assessment Scale
Each rating should be considered in the context of what is appropriate for the age of your child. Is this evaluation
based on a time when the child
□ was on medication □ was not on medication.
Please answer all questions.
Never Occasionally Often Very
Often
1. Does not pay attention to details or makes careless
mistakes with, for example, homework.
0 1 2 3
2. Has difficulty keeping attention to what needs to
be done.
0 1 2 3
3. Does not seem to listen when spoken to directly. 0 1 2 3
4. Does not follow through when given directions
and fails to finish activities (not due to refusal or
misunderstanding).
0 1 2 3
5. Has difficulty organizing tasks and activities. 0 1 2 3
6. Avoids, dislikes, or does not want to start tasks
that require ongoing mental effort.
0 1 2 3
7. Loses things necessary for tasks or activities (toys,
assignments, pencils, or books).
0 1 2 3
8. Is easily distracted by noises or other stimuli. 0 1 2 3
9. Is forgetful in daily activities. 0 1 2 3
Total:
10. Fidgets with hands or feet or squirms in seat. 0 1 2 3
11. Leaves seat when remaining seated is expected. 0 1 2 3
12. Runs about or climbs too much when remaining
seated is expected.
0 1 2 3
13. Has difficulty playing or beginning quiet play
activities.
0 1 2 3
14. Is “on the go” or often acts as if “driven by a
motor.”
0 1 2 3
15. Talks too much. 0 1 2 3
16. Blurts out answers before questions have been
completed.
0 1 2 3
17. Has difficulty waiting his/her turn. 0 1 2 3
18. Interrupts or intrudes in on others’ conversations
and/or activities.
0 1 2 3
Total:
South East Bay Pediatrics (12/04)
4
19. Argues with adults. 0 1 2 3
20. Loses temper. 0 1 2 3
21. Actively defies or refuses to go along with adults’
requests or rules.
0 1 2 3
22. Deliberately annoys people. 0 1 2 3
23. Blames others for his or her mistakes or
misbehaviors.
0 1 2 3
24. Is touchy or easily annoyed by others. 0 1 2 3
25. Is angry or resentful. 0 1 2 3
26. Is spiteful and wants to get even. 0 1 2 3
Total:
27. Bullies, threatens, or intimidates others. 0 1 2 3
28. Starts physical fights. 0 1 2 3
29. Lies to get out of trouble or to avoid obligations
(i.e. “cons” others).
0 1 2 3
30. Is truant from school (skips school) without
permission.
0 1 2 3
31. Is physically cruel to people. 0 1 2 3
32. Has stolen things that have value. 0 1 2 3
33. Deliberately destroys others’ property. 0 1 2 3
34. Has used a weapon that can cause serious harm
(bat, knife, brick, gun).
0 1 2 3
35. Is physically cruel to animals. 0 1 2 3
36. Has deliberately set fires to cause damage. 0 1 2 3
37. Has broken into someone else’s home, business,
car.
0 1 2 3
38. Has stayed out at night without permission. 0 1 2 3
39. Has run away from home overnight. 0 1 2 3
Total:
40. Has forced someone into sexual activity. 0 1 2 3
41. Is fearful, anxious, or worried. 0 1 2 3
42. Is afraid to try new things for fear of making
mistakes.
0 1 2 3
43. Feels worthless or inferior. 0 1 2 3
44. Blames self for problems, feels guilty. 0 1 2 3
45. Feels lonely, unwanted, or unloved; complains
that “no one loves him/her”).
0 1 2 3
46. Is sad, unhappy, or depressed. 0 1 2 3
47. Is self-conscious or easily embarrassed. 0 1 2 3
Total:
South East Bay Pediatrics (12/04)
5
Performance
Excellent Above
Average
Average Somewhat of
a Problem
Problematic
Overall school performance 1 2 3 4 5
Reading 1 2 3 4 5
Writing 1 2 3 4 5
Mathematics 1 2 3 4 5
Relationship with parents 1 2 3 4 5
Relationship with siblings 1 2 3 4 5
Relationship with peers 1 2 3 4 5
Participation in organized activities. 1 2 3 4 5
Severity or Impairment
Considering your total experience with this child, how severely impaired is he/she at this time?
Compare this child to average normal children you are familiar with from your totality of
experience. Please circle the number that best describes this child.
Normal,
No Impairment
1
Symptoms are not present any more than expected (of a typical child of the
same age and gender in the same situations) and do not produce impairment of
normal functioning at home or at school.
Slight
Impairment
2
Symptoms are present a little more frequently or intensely than expected (of a
typical child of the same age and gender in the same situations) and only
rarely produce impairment of normal functioning at home or school.
Mild
Impairment
3
Symptoms are present somewhat more frequently or intensely than expected
(of a typical child of the same age and gender in the same situations) and only
sometimes produce impairment of normal functioning at home or school.
Moderate
Impairment
4
Symptoms are present a lot more frequently or intensely than expected (of a
typical child of the same age and gender in the same situations) and usually
produce impairment of normal functioning at home or school.
Severe
Impairment
5
Symptoms are present a great deal more frequently or intensely than expected
(of a typical child of the same age and gender in the same situations) and most
of the time produce impairment of normal functioning at home or school.
Very Severe
Impairment
6
Symptoms are present so much more frequently or intensely than expected (of
a typical child of the same age and gender in the same situations) that they
almost always produce impairment of normal functioning at home or school.
Maximal,
Profound
Impairment
7
Symptoms are present so frequently or intensely that they produce significant
and pervasive impairment, which creates a crisis requiring immediate action
to prevent serious deterioration, to avoid danger, or to prevent harm.
South East Bay Pediatrics (12/04)
