For caregivers of children with ADHD

Child's Name:

Sex: M F

Age:

Completed by: Mother Father Guardian

The following questionnaire is intended to help reassess your child's ADHD symptoms while on his/her current treatment plan across multiple life settings: School Time, Activity Time, Homework Time, and Family and Play Time.

Once you have completed this questionnaire, please return it to your child's doctor. The doctor can review the results, conduct a clinical evaluation, and if necessary, discuss the results further with you.

Setting 1: School Time

INSTRUCTIONS: Based on teachers' reports, please check the box that best describes to what degree the following symptoms have impacted your child at school over the past 6 months.
1.	Pays attention in class or ignores disruptions by peers	Not at all	Somewhat	A lot
2.	Completes classroom assignments and tests on time	Not at all	Somewhat	A lot
3.	The extent to which your child interrupts classmates, leaves his/her seat, or blurts out answers	Not at all	Somewhat	A lot
4.	Speak to doctor about my child's ADHD symptoms at school	Yes	No

Setting 2: Activity Time

INSTRUCTIONS: Based on feedback from coaches and other after-school caregivers, please check the box that best describes to what degree the following symptoms have impacted your child during after-school activities over the past 6 months.
1.	Pays attention and focuses during extracurricular activities (for example, music lessons, sport activities, scout meetings)	Not at all	Somewhat	A lot
2.	Waits his/her turn during extracurricular activities	Not at all	Somewhat	A lot
3.	Listens when spoken to directly while participating in extracurricular activities	Not at all	Somewhat	A lot
4.	Speak to doctor about my child's ADHD symptoms during activity time	Yes	No

Setting 3: Homework Time

INSTRUCTIONS: Based on your observations and input from other family members, please check the box that best describes to what degree the following symptoms have impacted your child during homework time over the past 6 months.
1.	Focuses on homework and remains undistracted	Not at all	Somewhat	A lot
2.	Organizes homework assignments	Not at all	Somewhat	A lot
3.	The extent to which your child squirms, fidgets, or leaves the seat when expected to sit and finish homework	Not at all	Somewhat	A lot
4.	Gives close attention to detail (for example, work is not messy or incomplete, or he/she avoids making careless mistakes)	Not at all	Somewhat	A lot
5.	Speak to doctor about my child's ADHD symptoms during homework time	Yes	No

Setting 4: Family and Play Time

INSTRUCTIONS: Check the box that best describes to what degree the following symptoms have impacted your child in social settings over the past 6 months.
1.	Stays seated while eating dinner with family members	Not at all	Somewhat	A lot
2.	The extent to which your child talks excessively	Not at all	Somewhat	A lot
3.	The extent to which your child runs about and climbs excessively in inappropriate situations	Not at all	Somewhat	A lot
4.	Follows through on chores or other duties requiring multiple steps	Not at all	Somewhat	A lot
5.	Speak to doctor about my child's ADHD symptoms during family and play time	Yes	No

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Important Safety Information

Vyvanse is indicated for the treatment of ADHD. Efficacy based on two controlled trials in children aged 6 to 12 and one controlled trial in adults.

Tell the doctor about any heart conditions, including structural abnormalities, that you, your child, or a family member, may have. Inform the doctor immediately if you or your child develops symptoms that suggest heart problems, such as chest pain or fainting.

Vyvanse should not be taken if you or your child has advanced disease of the blood vessels (arteriosclerosis); symptomatic heart disease; moderate to severe high blood pressure; overactive thyroid gland (hyperthyroidism); known allergy or unusual reactions to drugs called sympathomimetic amines (for example, pseudoephedrine); seizures; glaucoma; a history of problems with alcohol or drugs; agitated states; taken a monoamine oxidase inhibitor (MAOI) within the last 14 days.

Tell the doctor before taking Vyvanse if you or your child is being treated for or has symptoms of depression (sadness, worthlessness, or hopelessness) or bipolar disorder; has abnormal thought or visions, hears abnormal sounds, or has been diagnosed with psychosis; has had seizures or abnormal EEGs; has or has had high blood pressure; exhibits aggressive behavior or hostility. Tell the doctor immediately if you or your child develops any of these conditions or symptoms while taking Vyvanse.

Abuse of amphetamines may lead to dependence. Misuse of amphetamine may cause sudden death and serious cardiovascular adverse events. These events have also been reported rarely with amphetamine use.

Talk to your health care provider if your child experiences slowing of growth (height and weight). Children should have their height and weight checked periodically while taking Vyvanse. Your health care provider may stop Vyvanse treatment if a problem is found during these check-ups.

Vyvanse was generally well tolerated in clinical studies. The most common side effects reported in studies of Vyvanse were: children—decreased appetite, difficulty falling asleep, stomachache, and irritability; adult—decreased appetite, difficulty falling asleep, and dry mouth.

Aggression, new abnormal thoughts/behaviors, mania, growth suppression, worsening of motion or verbal tics, and Tourette's syndrome have been associated with use of drugs of this type. Tell the doctor if you or your child has blurred vision while taking Vyvanse.

Please see Full Prescribing Information, including Medication Guide.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

VYV-00878 08/09

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