/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/questionnaires/,

/clinical/cckm-tools/content/questionnaires/name-97139-en.cckm

201706158

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Questionnaires

NICHQ Vanderbilt Assessment Scale - Teacher Informant (301813-DT)

NICHQ Vanderbilt Assessment Scale - Teacher Informant (301813-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire - Health
UWH301813-DT (Rev.06/02/17) NICHQ VANDERBILT ASSESSMENT SCALE – TEACHER INFORMANT
Page 1 of 3

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
NICHQ VANDERBILT ASSESSMENT
SCALE – TEACHER INFORMANT













Patient Name

DOB:

MR #

Index to Questionnaire - Health
UWH301813-DT (Rev.06/02/17) NICHQ VANDERBILT ASSESSMENT SCALE – TEACHER INFORMANT
Page 2 of 3

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
NICHQ VANDERBILT ASSESSMENT
SCALE – TEACHER INFORMANT


























Patient Name

DOB:

MR #

Index to Questionnaire - Health
UWH301813-DT (Rev.06/02/17) NICHQ VANDERBILT ASSESSMENT SCALE – TEACHER INFORMANT
Page 3 of 3

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
NICHQ VANDERBILT ASSESSMENT
SCALE – TEACHER 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 19–28: _____
Total number of questions scored 2 or 3 in questions 29–35: _____
Total number of questions scored 4 or 5 in questions 36–43: _____
Average Performance Score: _____


Please return this form to: _____________________________________ Fax Number: ________________________________
Mailing Address: ______________________________________________________________________________________________
____________________________________________________________________________________________________________