Table 6 UNIVERSITY OF VERMONT PARENT SURVEY (To be completed by the parent/guardian who is most involved in the student's care/daily life)
Relation to student: (Circle one) | Father | Mother | Legal Guardian | Other (specify): |
|---|---|---|---|---|
Number of hours child spends a day on Internet total: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
Number of hours a day child spends on computer games: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
Number hours a day child spends on console games (Playstation, Nintendo, etc.): (Circle one) | < 1 | 1–2 | 3–4 | >4 |
Number hours a day child spends watching television: (Circle one) | < 1 | 1–2 | 3–4 | >4 |
Has your son/daughter ever been diagnosed with: (Circle one) | Depression | Anxiety Disorder | ADD/ADHD | Other (specify): |
If so, for how many years? | ||||
Does your son/daughter have any other medical illnesses (diabetes, epilepsy, etc.)? | Yes | No | If so, please specify: | |
Is your son/daughter currently on any prescription medications? | Yes | No | ||
If so, please list medications: | ||||
Is your son/daughter: | NOT TRUE AT ALL (NEVER, SELDOM) | JUST A LITTLE TRUE (SOMETIMES) | PRETTY MUCH TRUE (OFTEN) | VERY MUCH TRUE (VERY OFTEN) |
1 Inattentive, easily distracted | ||||
2 Angry and resentful | ||||
3 Difficulty doing or completing homework | ||||
4 Always "on the go" | ||||
5 Short attention span | ||||
6 Argues with adults | ||||
7 Fidgets with hands/feet, squirm in seat | ||||
8 Fails to complete assignments on time | ||||
9 Hard to control in malls or grocery shopping | ||||
10 Messy or disorganized at home or school | ||||
11 Loses temper | ||||
12 Needs close supervision to get through assignments | ||||
13 Only attends if it is something he/she is very interested in | ||||
14 Runs or climbs excessively in situations where it is inappropriate | ||||
15 Distractibility or attention span a problem | ||||
16 Irritable | ||||
17 Avoids, expresses reluctance about, or has difficulty engaging in tasks that require sustained mental effort (such as school work or homework) | ||||
18 Restless in the "squirmy" sense | ||||
19 Gets distracted when given instruction to do something | ||||
20 Actively defies or refuses to comply with adults' requests | ||||
21 Has trouble concentrating in class | ||||
22 has difficulty waiting in lines or awaiting turn in games or group situations | ||||
23 Leaves seat in classroom or other situation in which remaining seated is expected | ||||
24 Deliberately does things that annoy other people | ||||
25 Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace | ||||
26 has difficulty playing or engaging in leisure activities quietly | ||||
27 Easily frustrated in efforts | ||||