Dyspraxia Assessment Form



    

This form is split into multiple pages, please complete each page using the tabs below before submitting your application on the last page.

At the end of the process you will be given the opportunity to print a copy of the application for your own records.

Alternatively you can download a blank form in word format here

  1. Personal details
  2. Health 1
  3. Health 2
  4. Health 3
  5. Confirmation

Any information entered in this form is held in the stricted confidence and is not shared with any third party.

Personal Details

(dd/mm/yyyy)

Please scroll back up to the top and complete the form's next page.

History of Pregnancy

Premature | Normal | Postmature

Yes | No

Yes | No

Yes | No

Yes | No

Yes | No

Yes | No

Yes | No

Yes | No

Please scroll back up to the top and complete the form's next page.

General Health

Motor Development

Vision

Hearing

Eating / Drinking

Communication

Dressing / Undressing

Please scroll back up to the top and complete the form's next page.

Current Treatments

Physiotherapy

Speech & Language Therapy

Occupational Therapy

General

Education

Please give contact name, address and telephone number for each

Please scroll back up to the top and complete the form's next page.

Confirmation

I declare that, to the best of my knowledge and belief, the information I have given in this form is true and accurate.

(dd/mm/yyyy)