SNAP IV 26

Child's Name
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Gender
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Age
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Date of Birth
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Health Card #(*)
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Psychiatrist
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Grade
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Type of Class
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Class Size
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Completed By
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Relationship to Patient
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Date
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For each item, check the column which best describes this child in the last month:


1. Often fails to give close attention to details or makes careless mistakes in school work
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2. Often has difficulty sustaining attention in tasks or play activities
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3. Often does not seem to listen when spoken to directly
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4. Often does not follow through on instructions and fails to finish schoolwork, chores or duties
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5. Often has difficulty organizing tasks and activities
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6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort
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7. Often loses things necessary for activities (e.g. toys, school assignments, pencils, or books)
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8. Often is distracted by extraneous stimuli
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9. Often is forgetful in daily activities
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10. Often fidgets with hands or feet or squirms in seat
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11. Often leaves seat in classroom or in other situations when remaining seated is expected
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12. Often runs about or climbs excessively in situations where it is inappropriate
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13. Often has difficulty playing or engaging in leisure activities quietly
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14. Often is “on the go” or often acts as if “driven by a motor”
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15. Often talks excessively
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16. Often blurts out answers to questions before the questions have been completed
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17. Often has difficulty awaiting turn
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18. Often interrupts or intrudes on others (e.g., butts into conversations/games)
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19. Often loses temper
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20. Often argues with adults
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21. Often actively defies or refuses adult requests or rules
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22. Often deliberately does things that annoy other people
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23. Often blames others for his or her mistakes or misbehavior
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24. Often touchy or easily annoyed by others
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25. Often is angry and resentful
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26. Often is spiteful or vindictive
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