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NICHQ Vanderbilt Assessment Scale - Parent Informant (301812-DT)

NICHQ Vanderbilt Assessment Scale - Parent Informant (301812-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #


UWH# 301812-DT (Rev. 03/17/16) Scan to Questionnaire – Health NICHQ VANDERBILT ASSESSMENT
SCALE – PARENT INFORMANT Page 1 of 3
University of Wisconsin Hospitals and Clinics
NICHQ VANDERBILT ASSESSMENT SCALE
– PARENT INFORMANT
















Patient Name

DOB:

MR #


UWH# 301812-DT (Rev. 03/17/16) Scan to Questionnaire – Health NICHQ VANDERBILT ASSESSMENT
SCALE – PARENT INFORMANT Page 2 of 3
University of Wisconsin Hospitals and Clinics
NICHQ VANDERBILT ASSESSMENT SCALE
– PARENT INFORMANT




















Patient Name

DOB:

MR #


UWH# 301812-DT (Rev. 03/17/16) Scan to Questionnaire – Health NICHQ VANDERBILT ASSESSMENT
SCALE – PARENT INFORMANT Page 3 of 3
University of Wisconsin Hospitals and Clinics
NICHQ VANDERBILT ASSESSMENT SCALE
– PARENT INFORMANT











































Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.


Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________


Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM




For Office Use Only
Total Number of questions scored 2 or 3 in questions 1–9: _____
Total number of questions scored 2 or 3 in questions 10–18: _____
Total Symptom Score for questions 1–18: _____
Total number of questions scored 2 or 3 in questions 19–26: _____
Total number of questions scored 2 or 3 in questions 27–40: _____
Total number of questions scored 2 or 3 in questions 41–47: _____
Total number of questions scored 4 or 5 in questions 48–55: _____
Average Performance Score: _____