| Headaches: |
{{ $data['patient-intake-form-pdf-form']->headaches }} |
| Feelings Of Dizziness: |
{{ $data['patient-intake-form-pdf-form']->feelings_of_dizziness }} |
| Nausea And/Or Vomiting: |
{{ $data['patient-intake-form-pdf-form']->nausea_and_or_vomiting }} |
| Noise Sensitivity: |
{{ $data['patient-intake-form-pdf-form']->noise_sensitivity }} |
| Sleep Disturbance: |
{{ $data['patient-intake-form-pdf-form']->sleep_disturbance }} |
| Fatigue: |
{{ $data['patient-intake-form-pdf-form']->fatigue }} |
| Irritability: |
{{ $data['patient-intake-form-pdf-form']->irritability }} |
| Feeling Depressed Or Tearful: |
{{ $data['patient-intake-form-pdf-form']->feeling_depressed_or_tearful }} |
| Feeling Frustrated: |
{{ $data['patient-intake-form-pdf-form']->feeling_frustrated }} |
| Forgetfulness: |
{{ $data['patient-intake-form-pdf-form']->forgetfulness }} |
| Poor Concentration: |
{{ $data['patient-intake-form-pdf-form']->poor_concentration }} |
| Taking Longer To Think: |
{{ $data['patient-intake-form-pdf-form']->taking_longer_to_think }} |
| Blurred Vision: |
{{ $data['patient-intake-form-pdf-form']->blurred_vision }} |
| Light Sensitivity: |
{{ $data['patient-intake-form-pdf-form']->light_sensitivity }} |
| Double Vision: |
{{ $data['patient-intake-form-pdf-form']->double_vision }} |
| Restlessness: |
{{ $data['patient-intake-form-pdf-form']->restlessness }} |
| Other Difficulties Text: |
{{ $data['patient-intake-form-pdf-form']->other_difficulties_text }} |
| Other Difficulties Value: |
{{ $data['patient-intake-form-pdf-form']->other_difficulties_value }} |
| Patient Name: |
{{ $data['patient-intake-form-pdf-form']->patient_name }} |
| Date Of Injury: |
{{ $data['patient-intake-form-pdf-form']->date_of_injury }} |
| Date Of Assessment: |
{{ $data['patient-intake-form-pdf-form']->date_of_assessment }} |
| Referral Signs: |
{{ $data['patient-intake-form-pdf-form']->referral_signs }} |
| Mechanism Of Injury: |
{{ $data['patient-intake-form-pdf-form']->mechanism_of_injury }} |
| Direct Head Contact: |
{{ $data['patient-intake-form-pdf-form']->direct_head_contact }} |
| Indirect Whiplash: |
{{ $data['patient-intake-form-pdf-form']->indirect_whiplash }} |
| Early Symptoms Experienced: |
{{ $data['patient-intake-form-pdf-form']->early_symptoms_experienced }} |
| Specialists / Evaluations: |
{{ $data['patient-intake-form-pdf-form']->specialists_evaluations }} |
| Imaging / Special Testing: |
{{ $data['patient-intake-form-pdf-form']->imaging_special_testing }} |
| Occupation At Time Of Injury: |
{{ $data['patient-intake-form-pdf-form']->occupation_at_time_of_injury }} |
| Current Work / Academic Load: |
{{ $data['patient-intake-form-pdf-form']->current_work_academic_load }} |
| Current/Ongoing Symptoms And Functional Limitations: |
{{ $data['patient-intake-form-pdf-form']->current_ongoing_symptoms_and_functional_limitations }} |
| Notes / Other: |
{{ $data['patient-intake-form-pdf-form']->notes_other }} |
| History Of patient: |
{{ $data['patient-intake-form-pdf-form']->history_of_patient }} |
| Relevant Medical History: |
{{ $data['patient-intake-form-pdf-form']->relevant_medical_history }} |
| Headache/Migraine History Pre-patient: |
{{ $data['patient-intake-form-pdf-form']->headache_migraine_history_pre_patient == 1 ? 'Yes' : 'No' }} |
| Headache/Migraine History If Yes: |
{{ $data['patient-intake-form-pdf-form']->headache_migraine_history_pre_patient_if_yes }} |
| Pre-Injury Anxiety / Depression: |
{{ $data['patient-intake-form-pdf-form']->pre_injury_anxiety_depression == 1 ? 'Yes' : 'No' }} |
| Pre-Injury Anxiety / Depression If Yes: |
{{ $data['patient-intake-form-pdf-form']->pre_injury_anxiety_depression_if_yes }} |
| History Of Learning Disability: |
{{ $data['patient-intake-form-pdf-form']->hx_of_learning_disability == 1 ? 'Yes' : 'No' }} |
| History Of Learning Disability If Yes: |
{{ $data['patient-intake-form-pdf-form']->hx_of_learning_disability_if_yes }} |
| Known Vestibular History: |
{{ $data['patient-intake-form-pdf-form']->any_known_vestibular_hx == 1 ? 'Yes' : 'No' }} |
| Known Vestibular History If Yes: |
{{ $data['patient-intake-form-pdf-form']->any_known_vestibular_hx_if_yes }} |
| History Of Motion Sickness: |
{{ $data['patient-intake-form-pdf-form']->hx_motion_sickness == 1 ? 'Yes' : 'No' }} |
| History Of Motion Sickness If Yes: |
{{ $data['patient-intake-form-pdf-form']->hx_motion_sickness_if_yes }} |
| Additional Notes: |
{{ $data['patient-intake-form-pdf-form']->additional_notes }} |
| Primary Insurance Name: |
{{ $data['patient-intake-form-pdf-form']->primary_insurance_name }} |
| Primary Member Name: |
{{ $data['patient-intake-form-pdf-form']->primary_member_name }} |
| Primary Policy Number: |
{{ $data['patient-intake-form-pdf-form']->primary_policy_number }} |
| Primary Certificate Number: |
{{ $data['patient-intake-form-pdf-form']->primary_certificate_number }} |
| Primary Date of Birth: |
{{ $data['patient-intake-form-pdf-form']->primary_dob }} |
| Primary Relationship: |
{{ $data['patient-intake-form-pdf-form']->primary_relationship }} |
| Secondary Insurance Name: |
{{ $data['patient-intake-form-pdf-form']->secondary_insurance_name }} |
| Secondary Member Name: |
{{ $data['patient-intake-form-pdf-form']->secondary_member_name }} |
| Secondary Policy Number: |
{{ $data['patient-intake-form-pdf-form']->secondary_policy_number }} |
| Secondary Certificate Number: |
{{ $data['patient-intake-form-pdf-form']->secondary_certificate_number }} |
| Secondary Date of Birth: |
{{ $data['patient-intake-form-pdf-form']->secondary_dob }} |
| Secondary Relationship: |
{{ $data['patient-intake-form-pdf-form']->secondary_relationship }} |
