SNAP-IV Short Form

1
Today's Date* This field is required.
Date
Month
Day
Year
2
Child's Name:* This field is required.
3
Child's Date of Birth* This field is required.
Date
Month
Day
Year
4
Is this evaluation based on a time when the child:* This field is required.
was on medication
was not on medication
not sure
5
Who is filling out this form?* This field is required.
Parent
Teacher
6
Relationship of parent filling the form to the child:
Mother
Father
Both parents filled it together
Stepmother
Stepfather
Other
7
Teacher's Name
8
Subjects taught by the teacher:
9
At what time of day do you typically teach these subjects? Check ALL that apply:
Early morning
Late morning
Early afternoon
Late afternoon
Other
10
GROSS INATTENTION SCORE (Items 1-9): INTERPRETATION OF SCORES: < 13 = Symptoms not clinically significant 13 – 17 = Mild symptoms 18 – 22 = Moderate symptoms 23 – 26 = Severe symptoms
11
GROSS IMPULSIVITY HYPERACTIVITY SCORE: INTERPRETATION OF SCORES: < 13 = Symptoms not clinically significant 13 – 17 = Mild symptoms 18 – 22 = Moderate symptoms 23 – 26 = Severe symptoms
12
Interpretation of Gross Inattention & Impulsivity Hyperactivity Scores

Total Score Interpretation

0 - 12 Symptoms not clinically significant

13 - 17 Mild symptoms

18 - 22 Moderate symptoms

23 - 26 Severe symptoms
13
GROSS OPPOSITIONAL DEFIANCE SCORE:INTERPRETATION OF SCORES: < 8 = Symptoms not clinically significant 8–13 = Mild symptoms 14–18 = Moderate symptoms 19–24 = Severe symptoms
14
Interpretation of Gross Oppositional Defiance Scores

Total Score Interpretation

0 - 7 Symptoms not clinically significant

8 - 13 Mild symptoms

14 - 18 Moderate symptoms

19 - 24 Severe symptoms
15
AVERAGE INATTENTION SCORE (Items 1-9):
16
AVERAGE IMPULSIVITY HYPERACTIVITY SCORE (Items 10-18):
17
AVERAGE ADHD SCORES (Items 1-18):
18
AVERAGE OPPOSITIONAL DEFIANCE SCORE (Items 19-26):
19
Interpretation of Average Scores

Total Score Interpretation

<1 Not at all

1 - 2 Just a little

2 - 3 Quite a bit

3 - 4 Very much
20
DIRECTIONS: In the next 26 items, please choose the option that best reflects how often or how much you've noticed each symptom or behavior in the child over the past month.
21
1. Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks.* This field is required.
Not at all
Just a little
Quite a bit
Very much
22
2. Often has difficulty sustaining attention in tasks or play activities.* This field is required.
Not at all
Just a little
Quite a bit
Very much
23
3. Often does not seem to listen when spoken to directly.* This field is required.
Not at all
Just a little
Quite a bit
Very much
24
4. Often does not follow through on instructions and fails to finish school work, chores, or duties.* This field is required.
Not at all
Just a little
Quite a bit
Very much
25
5. Often has difficulty organizing tasks and activities.* This field is required.
Not at all
Just a little
Quite a bit
Very much
26
6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort.* This field is required.
Not at all
Just a little
Quite a bit
Very much
27
7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, or books.)* This field is required.
Not at all
Just a little
Quite a bit
Very much
28
8. Often is distracted by extraneous stimuli.* This field is required.
Not at all
Just a little
Quite a bit
Very much
29
9. Often is forgetful in daily activities.* This field is required.
Not at all
Just a little
Quite a bit
Very much
30
10. Often fidgets with hands or feet or squirms in seat.* This field is required.
Not at all
Just a little
Quite a bit
Very much
31
11. Often leaves seat in classroom or in other situations in which* This field is required.
Not at all
Just a little
Quite a bit
Very much
32
12. Often runs or climbs excessively in situations in which it is* This field is required.
Not at all
Just a little
Quite a bit
Very much
33
13. Often has difficulty playing or engaging in leisure activities quietly.* This field is required.
Not at all
Just a little
Quite a bit
Very much
34
14. Often is "on the go" or acts as if "driven by a motor."* This field is required.
Not at all
Just a little
Quite a bit
Very much
35
15. Often talks excessively.* This field is required.
Not at all
Just a little
Quite a bit
Very much
36
16. Often blurts out answers before questions have been completed.* This field is required.
Not at all
Just a little
Quite a bit
Very much
37
17. Often has difficulty awaiting turn.* This field is required.
Not at all
Just a little
Quite a bit
Very much
38
18. Often interrupts or intrudes on others (e.g., butts into* This field is required.
Not at all
Just a little
Quite a bit
Very much
39
19. Often loses temper.* This field is required.
Not at all
Just a little
Quite a bit
Very much
40
20. Often argues with adults.* This field is required.
Not at all
Just a little
Quite a bit
Very much
41
21. Often actively defies or refuses adult requests or rules.* This field is required.
Not at all
Just a little
Quite a bit
Very much
42
22. Often deliberately does things that annoy other people.* This field is required.
Not at all
Just a little
Quite a bit
Very much
43
23. Often blames others for his/her mistakes or misbehaviors.* This field is required.
Not at all
Just a little
Quite a bit
Very much
44
24. Often touchy or easily annoyed by others.* This field is required.
Not at all
Just a little
Quite a bit
Very much
45
25. Often is angry and resentful.* This field is required.
Not at all
Just a little
Quite a bit
Very much
46
26. Often is spiteful or vindictive.* This field is required.
Not at all
Just a little
Quite a bit
Very much
47
Additional CommentsUse this space to provide any further comments that may be relevant to the child's behavior, academic performance, emotional health or psychological well-being. Your insights are invaluable and will help us offer the best possible care and support for the child.
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Large
Normal
Small
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Ok
Should be Empty:

Total Score	Interpretation
0 - 12	Symptoms not clinically significant
13 - 17	Mild symptoms
18 - 22	Moderate symptoms
23 - 26	Severe symptoms

Total Score	Interpretation
0 - 7	Symptoms not clinically significant
8 - 13	Mild symptoms
14 - 18	Moderate symptoms
19 - 24	Severe symptoms

Total Score	Interpretation
<1	Not at all
1 - 2	Just a little
2 - 3	Quite a bit
3 - 4	Very much