Cerebral Palsy 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

General Health

Child's Present Condition

Yes | No

Yes | No

Yes | No

Vision

Hearing

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Education

Please give contact name, address and telephone number for each

Current Treatments

Physiotherapy

Speech & Language Therapy

Occupational Therapy

General

Special Aids

Motor Development

With support
Unaided
On a chair/stool
On the floor
Other

Yes | No

Rolling
Creeping
Crawling
Standing up/standing
Walking

Grasp/release
Flat hands
Isolate thumb/index finger
Pincer grasp
Does the child demonstrate preference for one hand?
Does the child transfer toys etc. from one hand to the other?
Can the child put hands together in midline (e.g. clap, clasp)

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

Communication

Sounds
Babbling
Words - how many? Clarity?
Non-verbal
High/low tech communication aids

Eating and Drinking

Finger feeding
Spoon
Fork
Knife and fork
Bottle
Beaker with spout
Cup
Straw

Learning Abilities

Behaviour

Happy
Unhappy
Irritable
Crying a lot
Apathy
Passive
Restless
Restful
Demanding
Manipulative

Sleeping

Yes | No

Dressing

Yes | No

Toileting

Yes | No

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)