| Patient Name: |
{{ $data->patient_name }} |
| Date |
{{ $data->date }} |
| Family Doctor's Name |
{{ $data->doctor_name }} |
| Doctors Phone No |
{{ $data->doctor_phone }} |
| Do you have any heart problems? |
{{ $data->has_heart_problems == 1 ? 'Yes' : 'No' }} |
| Do you have any thyroid problems? |
{{ $data->has_thyroid_problems == 1 ? 'Yes' : 'No' }} |
| Do you have HIGH or LOW blood pressure? |
{{ $data->has_blood_pressure == 1 ? 'Yes' : 'No' }} |
| Are you currently taking any medications? |
{{ $data->taking_medications == 1 ? 'Yes' : 'No' }} |
| If yes, please list |
{{ $data->medication_list }} |
| Have you been diagnosed with arthritis? |
{{ $data->has_arthritis == 1 ? 'Yes' : 'No' }} |
| Do you have diabetes? |
{{ $data->has_diabetes == 1 ? 'Yes' : 'No' }} |
| Do you have or ever had cancer? |
{{ $data->cancer == 1 ? 'Yes' : 'No' }} |
| Have you ever broken a bone? |
{{ $data->has_broken_bone == 1 ? 'Yes' : 'No' }} |
| Do you have any metal fixations, plates, screws, etc.? |
{{ $data->has_metal_fixations == 1 ? 'Yes' : 'No' }} |
| Do you smoke? |
{{ $data->do_you_smoke == 1 ? 'Yes' : 'No' }} |
| How much |
{{ $data->smoke_much }} |
| Do you have any abdominal problems, ie hernia, ulcer? |
{{ $data->has_abdominal_problems == 1 ? 'Yes' : 'No' }} |
| Have you had any previous surgeries |
{{ $data->has_previous_surgeries == 1 ? 'Yes' : 'No' }} |
| Previous surgeries list |
{{ $data->previous_surgeries_list }} |
| If female, are you or could you be pregnant? |
{{ $data->is_pregnant == 1 ? 'Yes' : 'No' }} |
| Have you been involved in a previous car accident? |
{{ $data->has_car_accident == 1 ? 'Yes' : 'No' }} |
| Accident Date |
{{ $data->car_accident_date }} |
| Do you have any allergies, skin irritations, infections, etc? |
{{ $data->has_allergies == 1 ? 'Yes' : 'No' }} |
| Do you have asthma or any respiratory problems? |
{{ $data->asthma == 1 ? 'Yes' : 'No' }} |
| Do you have any other health problems not listed above? |
{{ $data->has_other_health_problems == 1 ? 'Yes' : 'No' }} |
| Is there any other reason that you should not do physical activities? |
{{ $data->has_other_reason == 1 ? 'Yes' : 'No' }} |
| When was your last Physiotherapy visit |
{{ $data->last_physiotherapy_visit }} |
| Where was your last Physiotherapy visit |
{{ $data->last_physiotherapy_location }} |
| Emergency contact person |
{{ $data->emergency_contact_person }} |
| Emergency Phone |
{{ $data->emergency_phone }} |
| Client’s Signature |
{{ $data->client_signature }} |
Thank you for contacting us.
We have received your Form Submission our Staff will be contacting you within 24 hours.
Have a great day ahead!
|
