| Primary Insurance Name: |
{{ $data['concussion-intake-form-pdf-form']->primary_insurance_name }} |
| Primary Member Name: |
{{ $data['concussion-intake-form-pdf-form']->primary_member_name }} |
| Primary Policy Number: |
{{ $data['concussion-intake-form-pdf-form']->primary_policy_number }} |
| Primary Certificate Number: |
{{ $data['concussion-intake-form-pdf-form']->primary_certificate_number }} |
| Primary Date of Birth: |
{{ $data['concussion-intake-form-pdf-form']->primary_dob }} |
| Primary Relationship: |
{{ $data['concussion-intake-form-pdf-form']->primary_relationship }} |
| Secondary Insurance Name: |
{{ $data['concussion-intake-form-pdf-form']->secondary_insurance_name }} |
| Secondary Member Name: |
{{ $data['concussion-intake-form-pdf-form']->secondary_member_name }} |
| Secondary Policy Number: |
{{ $data['concussion-intake-form-pdf-form']->secondary_policy_number }} |
| Secondary Certificate Number: |
{{ $data['concussion-intake-form-pdf-form']->secondary_certificate_number }} |
| Secondary Date of Birth: |
{{ $data['concussion-intake-form-pdf-form']->secondary_dob }} |
| Secondary Relationship: |
{{ $data['concussion-intake-form-pdf-form']->secondary_relationship }} |
| Headaches: |
{{ $data['concussion-intake-form-pdf-form']->headaches }} |
| Feelings Of Dizziness: |
{{ $data['concussion-intake-form-pdf-form']->feelings_of_dizziness }} |
| Nausea And/Or Vomiting: |
{{ $data['concussion-intake-form-pdf-form']->nausea_and_or_vomiting }} |
| Noise Sensitivity: |
{{ $data['concussion-intake-form-pdf-form']->noise_sensitivity }} |
| Sleep Disturbance: |
{{ $data['concussion-intake-form-pdf-form']->sleep_disturbance }} |
| Fatigue: |
{{ $data['concussion-intake-form-pdf-form']->fatigue }} |
| Irritability: |
{{ $data['concussion-intake-form-pdf-form']->irritability }} |
| Feeling Depressed Or Tearful: |
{{ $data['concussion-intake-form-pdf-form']->feeling_depressed_or_tearful }} |
| Feeling Frustrated: |
{{ $data['concussion-intake-form-pdf-form']->feeling_frustrated }} |
| Forgetfulness: |
{{ $data['concussion-intake-form-pdf-form']->forgetfulness }} |
| Poor Concentration: |
{{ $data['concussion-intake-form-pdf-form']->poor_concentration }} |
| Taking Longer To Think: |
{{ $data['concussion-intake-form-pdf-form']->taking_longer_to_think }} |
| Blurred Vision: |
{{ $data['concussion-intake-form-pdf-form']->blurred_vision }} |
| Light Sensitivity: |
{{ $data['concussion-intake-form-pdf-form']->light_sensitivity }} |
| Double Vision: |
{{ $data['concussion-intake-form-pdf-form']->double_vision }} |
| Restlessness: |
{{ $data['concussion-intake-form-pdf-form']->restlessness }} |
| Other Difficulties Text: |
{{ $data['concussion-intake-form-pdf-form']->other_difficulties_text }} |
| Other Difficulties Value: |
{{ $data['concussion-intake-form-pdf-form']->other_difficulties_value }} |
| Patient Name: |
{{ $data['concussion-intake-form-pdf-form']->patient_name }} |
| Date Of Injury: |
{{ $data['concussion-intake-form-pdf-form']->date_of_injury }} |
| Date Of Assessment: |
{{ $data['concussion-intake-form-pdf-form']->date_of_assessment }} |
| Referral Signs: |
{{ $data['concussion-intake-form-pdf-form']->referral_signs }} |
| Mechanism Of Injury: |
{{ $data['concussion-intake-form-pdf-form']->mechanism_of_injury }} |
| Direct Head Contact: |
{{ $data['concussion-intake-form-pdf-form']->direct_head_contact }} |
| Indirect Whiplash: |
{{ $data['concussion-intake-form-pdf-form']->indirect_whiplash }} |
| Early Symptoms Experienced: |
{{ $data['concussion-intake-form-pdf-form']->early_symptoms_experienced }} |
| Specialists / Evaluations: |
{{ $data['concussion-intake-form-pdf-form']->specialists_evaluations }} |
| Imaging / Special Testing: |
{{ $data['concussion-intake-form-pdf-form']->imaging_special_testing }} |
| Occupation At Time Of Injury: |
{{ $data['concussion-intake-form-pdf-form']->occupation_at_time_of_injury }} |
| Current Work / Academic Load: |
{{ $data['concussion-intake-form-pdf-form']->current_work_academic_load }} |
| Current/Ongoing Symptoms And Functional Limitations: |
{{ $data['concussion-intake-form-pdf-form']->current_ongoing_symptoms_and_functional_limitations }} |
| Notes / Other: |
{{ $data['concussion-intake-form-pdf-form']->notes_other }} |
| History Of Concussion: |
{{ $data['concussion-intake-form-pdf-form']->history_of_concussion }} |
| Relevant Medical History: |
{{ $data['concussion-intake-form-pdf-form']->relevant_medical_history }} |
| Headache/Migraine History Pre-Concussion: |
{{ $data['concussion-intake-form-pdf-form']->headache_migraine_history_pre_concussion == 1 ? 'Yes' : 'No' }} |
| Headache/Migraine History If Yes: |
{{ $data['concussion-intake-form-pdf-form']->headache_migraine_history_pre_concussion_if_yes }} |
| Pre-Injury Anxiety / Depression: |
{{ $data['concussion-intake-form-pdf-form']->pre_injury_anxiety_depression == 1 ? 'Yes' : 'No' }} |
| Pre-Injury Anxiety / Depression If Yes: |
{{ $data['concussion-intake-form-pdf-form']->pre_injury_anxiety_depression_if_yes }} |
| History Of Learning Disability: |
{{ $data['concussion-intake-form-pdf-form']->hx_of_learning_disability == 1 ? 'Yes' : 'No' }} |
| History Of Learning Disability If Yes: |
{{ $data['concussion-intake-form-pdf-form']->hx_of_learning_disability_if_yes }} |
| Known Vestibular History: |
{{ $data['concussion-intake-form-pdf-form']->any_known_vestibular_hx == 1 ? 'Yes' : 'No' }} |
| Known Vestibular History If Yes: |
{{ $data['concussion-intake-form-pdf-form']->any_known_vestibular_hx_if_yes }} |
| History Of Motion Sickness: |
{{ $data['concussion-intake-form-pdf-form']->hx_motion_sickness == 1 ? 'Yes' : 'No' }} |
| History Of Motion Sickness If Yes: |
{{ $data['concussion-intake-form-pdf-form']->hx_motion_sickness_if_yes }} |
| Additional Notes: |
{{ $data['concussion-intake-form-pdf-form']->additional_notes }} |
| CN I (Olfactory): |
{{ $data['concussion-intake-form-pdf-form']->cn_i_olfactory == 1 ? 'Clear' : 'Abn.' }} |
| CN II (Visual Fields, Pupillary Reflex): |
{{ $data['concussion-intake-form-pdf-form']->cn_ii_visual_fields_pupillary_reflex == 1 ? 'Clear' : 'Abn.' }} |
| CN III (H Pattern): |
{{ $data['concussion-intake-form-pdf-form']->cn_iii_h_pattern == 1 ? 'Clear' : 'Abn.' }} |
| CN IV (SO - Lat/Inf): |
{{ $data['concussion-intake-form-pdf-form']->cn_iv_so_lat_inf == 1 ? 'Clear' : 'Abn.' }} |
| CN V (Sensory/Mastication Mm): |
{{ $data['concussion-intake-form-pdf-form']->cn_v_sensory_mastication_mm == 1 ? 'Clear' : 'Abn.' }} |
| CN VI (LR-Lat): |
{{ $data['concussion-intake-form-pdf-form']->cn_vi_lr_lat == 1 ? 'Clear' : 'Abn.' }} |
| CN VII (Facial Expression Mm): |
{{ $data['concussion-intake-form-pdf-form']->cn_vii_facial_expression_mm == 1 ? 'Clear' : 'Abn.' }} |
| CN VIII (Nystagmus, Whisper): |
{{ $data['concussion-intake-form-pdf-form']->cn_viii_nystag_whisper == 1 ? 'Clear' : 'Abn.' }} |
| CN IX (Taste/Posterior Tongue): |
{{ $data['concussion-intake-form-pdf-form']->cn_ix_taste_posterior_tongue == 1 ? 'Clear' : 'Abn.' }} |
| CN X (Uvula, Swallow, Vocal Cords): |
{{ $data['concussion-intake-form-pdf-form']->cn_x_uvula_swallow_vocal_cords == 1 ? 'Clear' : 'Abn.' }} |
| CN XI (Trap, SCM): |
{{ $data['concussion-intake-form-pdf-form']->cn_xi_trap_scm == 1 ? 'Clear' : 'Abn.' }} |
| CN XII (Tongue Mm, Articulation): |
{{ $data['concussion-intake-form-pdf-form']->cn_xii_tongue_mm_articulation == 1 ? 'Clear' : 'Abn.' }} |
| Cerebellar Signs: |
{{ $data['concussion-intake-form-pdf-form']->cerebellar_signs == 1 ? 'Yes' : 'No' }} |
| UMN Signs: |
{{ $data['concussion-intake-form-pdf-form']->umn_signs == 1 ? 'Yes' : 'No' }} |
| Sensory Changes: |
{{ $data['concussion-intake-form-pdf-form']->sensory_changes == 1 ? 'Yes' : 'No' }} |
| Myotome Weakness: |
{{ $data['concussion-intake-form-pdf-form']->myotome_weakness == 1 ? 'Yes' : 'No' }} |
| DTRs: |
{{ $data['concussion-intake-form-pdf-form']->dtrs }} |
| VAST: |
{{ $data['concussion-intake-form-pdf-form']->vast == 1 ? 'Neg' : 'Pos' }} |
| 5Ds, 3Ns List: |
{{ $data['concussion-intake-form-pdf-form']->{'5ds_3ns_list'} }} |
| Gaze Fixation: |
{{ $data['concussion-intake-form-pdf-form']->gaze_fixation_1 }} |
| Gaze Fixation Findings: |
{{ $data['concussion-intake-form-pdf-form']->gaze_fixation_2 }} |
| Gaze Fixation Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->gaze_fixation_symptoms }} |
| NPC: |
{{ $data['concussion-intake-form-pdf-form']->npc_1 }} |
| NPC Break 1: |
{{ $data['concussion-intake-form-pdf-form']->npc_2 }} |
| NPC Break 2: |
{{ $data['concussion-intake-form-pdf-form']->npc_3 }} |
| NPC Break 3: |
{{ $data['concussion-intake-form-pdf-form']->npc_4 }} |
| NPC Findings: |
{{ $data['concussion-intake-form-pdf-form']->npc_5 }} |
| NPC Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->npc_symptoms }} |
| Accommodation: |
{{ $data['concussion-intake-form-pdf-form']->accommodation }} |
| Accommodation Notes: |
{{ $data['concussion-intake-form-pdf-form']->accommodation_notes }} |
| Pursuits: |
{{ $data['concussion-intake-form-pdf-form']->pursuits_1 }} |
| Pursuits Findings: |
{{ $data['concussion-intake-form-pdf-form']->pursuits_2 }} |
| Pursuits Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->pursuits_symptoms }} |
| Saccades: |
{{ $data['concussion-intake-form-pdf-form']->saccades_1 }} |
| Saccades Findings: |
{{ $data['concussion-intake-form-pdf-form']->saccades_2 }} |
| Saccades Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->saccades_symptoms }} |
| VOR: |
{{ $data['concussion-intake-form-pdf-form']->vor_1 }} |
| VOR Findings: |
{{ $data['concussion-intake-form-pdf-form']->vor_2 }} |
| VOR Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->vor_symptoms }} |
| VMS: |
{{ $data['concussion-intake-form-pdf-form']->vms_1 }} |
| VMS Findings: |
{{ $data['concussion-intake-form-pdf-form']->vms_2 }} |
| VMS Symptoms: |
{{ $data['concussion-intake-form-pdf-form']->vms_symptoms }} |
| Head Thrust Test: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_head_thrust_test }} |
| Dynamic Visual Acuity: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_dynamic_visual_acuity }} |
| Dynamic Visual Acuity Notes: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_dynamic_visual_acuity_text }} |
| Dix Hallpike: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_dix_hallpike }} |
| Dix Hallpike Notes: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_dix_hallpike_text }} |
| Lateral Position / Head Roll: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_lateral_pos_head_roll }} |
| Lateral Position / Head Roll Notes: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_lateral_pos_head_roll_text }} |
| Visual Fields (Confrontation): |
{{ $data['concussion-intake-form-pdf-form']->special_testing_visual_fields_confrontation_1 }} |
| Visual Fields Findings: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_visual_fields_confrontation_2 }} |
| Visual Fields Notes: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_visual_fields_confrontation_text }} |
| Special Testing Other: |
{{ $data['concussion-intake-form-pdf-form']->special_testing_other }} |
| Normal Gait: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_normal_gait_1 }} |
| Normal Gait Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_normal_gait_2 }} |
| Tandem Gait Eyes Open: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_1 }} |
| Tandem Gait Eyes Open Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_2 }} |
| Tandem Gait Eyes Closed: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_1 }} |
| Tandem Gait Eyes Closed Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_2 }} |
| Feet Together Firm Eyes Closed: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_feet_together_firm_eyes_closed_20s_1 }} |
| Feet Together Firm Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2 }} |
| Semi Tandem Firm Eyes Closed: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_1 }} |
| Semi Tandem Firm Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2 }} |
| Feet Together Foam Eyes Closed: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_feet_together_foam_eyes_closed_20s_1 }} |
| Feet Together Foam Findings: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2 }} |
| Balance And Gait Others: |
{{ $data['concussion-intake-form-pdf-form']->balance_and_gait_others }} |
| Upper Cervical Ligs: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_upper_cervical_ligs }} |
| Upper Cervical Ligs Notes: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_upper_cervical_ligs_text }} |
| Flexion (5°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_flexion_5d }} |
| Extension (60°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_extension_60d }} |
| Right Lateral Flexion (40-45°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_right_lateral_flexion_40_45d }} |
| Left Lateral Flexion (40-45°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_left_lateral_flexion_40_45d }} |
| Right Rotation (80°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_right_rotation_80d }} |
| Left Rotation (80°): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_left_rotation_80d }} |
| Range Of Motion Notes: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_range_of_motion_text }} |
| Upper Cervical (C1-C3): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_upper_cervical_c1_3 }} |
| Lower Cervical (C4-C7): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_lower_cervical_c4_7 }} |
| Joint Tenderness Notes: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_joint_tenderness_text }} |
| Suboccipital: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_suboccipital }} |
| Other: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_other }} |
| Myofascial Tone/Tenderness Notes: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_myofascial_tone_tenderness_text }} |
| Special Testing (C-Flex/Rot): |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_special_testing_c_flex_rot }} |
| Special Testing (C-Flex/Rot) Notes: |
{{ $data['concussion-intake-form-pdf-form']->cervical_ortho_screen_special_testing_c_flex_rot_text }} |
| Clinical Impression: |
{{ $data['concussion-intake-form-pdf-form']->clin_impression }} |
| Trajectories: |
{{ $data['concussion-intake-form-pdf-form']->trajectories }} |
| Referrals: |
{{ $data['concussion-intake-form-pdf-form']->referrals }} |
| POM: |
{{ $data['concussion-intake-form-pdf-form']->pom }} |
| Tests To Perform: |
{{ $data['concussion-intake-form-pdf-form']->tests_to_perform }} |
| Rehab To Initiate: |
{{ $data['concussion-intake-form-pdf-form']->rehab_to_initiate }} |
| Rehab To Initiate (If Others): |
{{ $data['concussion-intake-form-pdf-form']->rehab_to_initiate_if_others }} |
| Patient Aware Care To Be Shared With Kin And Consents: |
{{ $data['concussion-intake-form-pdf-form']->patient_aware_care_to_be_shared_w_kin_and_consents == 1 ? 'Yes' : 'No' }} |
| Name: |
{{ $data['concussion-intake-form-pdf-form']->name }} |
| Patient Signature: |
{{ $data['concussion-intake-form-pdf-form']->patient_signature }} |
| Patient Date: |
{{ $data['concussion-intake-form-pdf-form']->patient_date }} |
