ADHD School Questionnaire

ADHD School Questionnaire
Basic Information
Name of child:*

First NameLast Name
Date of birth:

DayMonthYear
Date
Gender:*

FemaleMale
Name of School and Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year Group:*
Name of person completing form:*

First NameLast Name
Date of form completion:*

DayMonthYear
Date
SNAP-IV-C Rating Scale
For each item, select the box that best describes this child. Put only one selection per item.
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities*

Not at allJust a littleQuite a bitVery much
2. Often has difficulty sustaining attention in tasks or play activities*

Not at allJust a littleQuite a bitVery much
3. Often does not seem to listen when spoken to directly*

Not at allJust a littleQuite a bitVery much
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties*

Not at allJust a littleQuite a bitVery much
5. Often has difficulty organising tasks and activities*

Not at allJust a littleQuite a bitVery much
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework)*

Not at allJust a littleQuite a bitVery much
7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)*

Not at allJust a littleQuite a bitVery much
8. Often is distracted by extraneous stimuli*

Not at allJust a littleQuite a bitVery much
9. Often is forgetful in daily activities*

Not at allJust a littleQuite a bitVery much
10. Often fidgets with hands or feet or squirms in seat*

Not at allJust a littleQuite a bitVery much
11. Often leaves seat in classroom or in other situations in which remaining seated is expected*

Not at allJust a littleQuite a bitVery much
12. Often runs about or climbs excessively in situations in which remaining seated is expected*

Not at allJust a littleQuite a bitVery much
13. Often has difficulty playing or engaging in leisure activities quietly*

Not at allJust a littleQuite a bitVery much
14. Often is “on the go” or often acts as if “driven by a motor”*

Not at allJust a littleQuite a bitVery much
15. Often talks excessively*

Not at allJust a littleQuite a bitVery much
16. Often blurts out answers before questions have been completed*

Not at allJust a littleQuite a bitVery much
17. Often has difficulty awaiting turn*

Not at allJust a littleQuite a bitVery much
18. Often interrupts or intrudes on others (e.g., butts into conversations/games)*

Not at allJust a littleQuite a bitVery much
19. Often loses temper*

Not at allJust a littleQuite a bitVery much
20. Often argues with adults*

Not at allJust a littleQuite a bitVery much
21. Often actively defies or refuses adult requests or rules*

Not at allJust a littleQuite a bitVery much
22. Often deliberately does things that annoy other people*

Not at allJust a littleQuite a bitVery much
23. Often blames others for his or her mistakes or misbehaviour*

Not at allJust a littleQuite a bitVery much
24. Often is touchy or easily annoyed by others*

Not at allJust a littleQuite a bitVery much
25. Often is angry and resentful*

Not at allJust a littleQuite a bitVery much
26. Often is spiteful or vindictive*

Not at allJust a littleQuite a bitVery much

Behavioural Presentation
Does the child display any difficulties concentrating on their work during lessons?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child ever act impulsively without thinking about the consequences of their actions?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child struggle to sit still during lessons?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child’s behaviour disturb other students during lessons?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child wander around the room during lessons?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child become angry or agitated when they feel that their needs are not being met?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child take up significantly more of your time than other students in the class?*

YesNo
Please give examples and explain how they cause difficulties in school.
Are there any concerns that the child is not reaching their academic potential due to any behavioural issues?*

YesNo
Please give examples and explain how they cause difficulties in school.
Does the child ever struggle to control their emotions or behaviour during lessons to an extent that their work or other students’ work is negatively impacted?*

YesNo
Please give examples and explain how they cause difficulties in school.
Are there any other concerns identified about the child’s mental health or behaviour during lessons?*

YesNo
Please give examples and explain how they cause difficulties in school.
Thank you for completing the form. Please click 'Submit' to send it to CAL.
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