Gagandeep Singh, M.D., LLC – SNAP-IV Rating Scale

Full Name

Phone *

Email *

Sex

Male

Female

For each item, check the column which best describes this child:

Often fails to give close attention to details or makes careless mistakes in work or tasks

Not at all

Just a little bit

Quite a bit

Very Much

Often has difficulty sustaining attention in tasks or activities

Not At All

Just A Little

Quite A Bit

Very Much

Often does not seem to listen when spoken to directly

Not At All

Just A Little

Quite A Bit

Very Much

Often does not follow through on instructions and fails to finish work, chores, or duties

Not At All

Just A Little

Quite A Bit

Very Much

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort

Not At All

Just A Little

Quite A Bit

Very Much

Often has difficulty organizing tasks and activities

Not At All

Just A Little

Quite A Bit

Very Much

Often loses things necessary for activities (e.g., daytimer, books, equipment)

Not At All

Just A Little

Quite A Bit

Very Much

Often is distracted by extraneous stimuli

Not At All

Just A Little

Quite A Bit

Very Much

Often fidgets with hands or feet or squirms in seat

Not At All

Just A Little

Quite A Bit

Very Much

Often is forgetful in daily activities

Not At All

Just A Little

Quite A Bit

Very Much

Often runs about or climbs excessively in situations in which it is inappropriate

Not At All

Just A Little

Quite A Bit

Very Much

Often leaves seat in situations in which remaining seated is expected

Not At All

Just A Little

Quite A Bit

Very Much

Often has difficulty engaging in leisure activities quietly

Not At All

Just A Little

Quite A Bit

Very Much

Often is “on the go” or often acts as if “driven by a motor”

Not At All

Just A Little

Quite A Bit

Very Much

Often blurts out answers before questions have been completed

Not At All

Just A Little

Quite A Bit

Very Much

Often talks excessively

Not At All

Just A Little

Quite A Bit

Very Much

Often has difficulty awaiting turn

Not At All

Just A Little

Quite A Bit

Very Much

Often interrupts or intrudes on others (e.g., butts into conversations/games)

Not At All

Just A Little

Quite A Bit

Very Much

Often loses temper

Not At All

Just A Little

Quite A Bit

Very Much

Often argues with family, friends, co-workers, supervisors

Not At All

Just A Little

Quite A Bit

Very Much

Often deliberately does things that annoy other people

Not At All

Just A Little

Quite A Bit

Very Much

Often blames others for his or her mistakes or misbehavior

Not At All

Just A Little

Quite A Bit

Very Much

Often is spiteful or vindictive

Not At All

Just A Little

Quite A Bit

Very Much

Often is angry and resentful

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty staying on task

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty getting started on work, tasks or assignment

Not At All

Just A Little

Quite A Bit

Very Much

Has problems in accuracy or neatness of written work

Not At All

Just A Little

Quite A Bit

Very Much

Has problems in completion of work in relation to tasks or assignments

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty making transitions to the next topic or task

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty attending to a group activity or discussion

Not At All

Just A Little

Quite A Bit

Very Much

Has problems in interactions with supervisors

Not At All

Just A Little

Quite A Bit

Very Much

Has problems in interactions with family, peers or co-workers

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty staying seated according to office rules

Not At All

Just A Little

Quite A Bit

Very Much

Has difficulty remaining quiet or behaving appropriately according to office rules

Not At All

Just A Little

Quite A Bit

Very Much

Change on medication?

Yes

No

What are the child’s strengths?

What is your main concern?

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