Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Arden House Medical Practice NHS GP Surgery in High Peak, Derbyshire

DCD screening questionnaire for parents / carers

DCD Screening Questionnaire for Parents / Carers

Child’s Details

Child’s Full Name: *

Date of Birth: *

Telephone Number:

Email Address: *

Name of GP:

Address (including postcode): *

Adults with Parental Responsibility

Full Name:

Relationship to Child:

Full Name:

Relationship to Child:

What are your main concerns (if any) regarding your child’s:

Physical Abilities:

Learning Abilities:

Social Abilities:

What would you consider to be your child’s strengths?

What are they good at?

What would they like to be better at?

Does your child have any additional support allocated in school?

Do you feel your child is generally happy and confident?

Yes

In what areas do they lack confidence?

e.g. school work, physical activities, independence.

In school does your child have an individual education plan?

Yes

Is your child interested in outdoor physical play?

Yes

Occasionally

e.g. playground, ball games, bike

Is your child interested in constructive/creative play?

Yes

Occasionally

e.g. Lego

Is your child interested in sedentary play?

Yes

Occasionally

e.g. Xbox, computers

Is your child interested in sedentary play?

Yes

Occasionally

e.g reading

Is your child interested in drawing/craft?

Yes

Occasionally

Is your child interested in imaginative play?

Yes

Occasionally

Please specify any after school clubs your child attends:

Please specify any other interests:

If you are human, leave this field blank.

Sett Close
New Mills
High Peak
SK22 4AQ

Get directions

01663 745266

Feedback and complaints

Wellbeing

Accessibility statement

Website policies