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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)

From: A cross-sectional analysis of video games and attention deficit hyperactivity disorder symptoms in adolescents

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     
  1. Thank you for taking part in our survey. All results are confidential. Please contact Philip Chan (research coordinator) at Philip.Chan@uvm.edu anytime with questions.
  2. PLEASE PLACE FINISHED SURVEY IN A SEALED ENVELOPE