@extends('themes.frontend.layouts.app')
@section('flatpickr') @stop
@section('validate') @stop

@if (isset($dataArr['meta_title']))
  @section('page-title'){{ $dataArr['meta_title'] }}@stop
@else
  @section('page-title'){{ $dataArr['title'] }}@stop
@endif
@if (isset($dataArr['meta_key']))
  @section('meta-keywords'){{ $dataArr['meta_key'] }}@stop
@endif
@if (isset($dataArr['meta_descp']))
  @section('meta-description'){{ $dataArr['meta_descp'] }}@stop
@endif
@if (isset($dataArr['image_path']))
  @section('meta-image'){{ $dataArr['image_path'] }}@stop
@endif
@if ($dataArr['full_url'])
  @section('cur-url'){{ $dataArr['full_url'] }}@stop
@endif

@push('styles')
@if(isset($dataArr['custom_fields']['textarea_4']) && $dataArr['custom_fields']['textarea_4'] && $dataArr['custom_fields']['textarea_4']['value'])
  <!--====== START: CUSTOM PAGE CSS from backed the Page ======-->
  <style scoped>
    {!! $dataArr['custom_fields']['textarea_4']['value'] !!}
  </style>
  <!--====== END: CUSTOM PAGE CSS from backed the Page ======-->
@endif
@endpush

@section('content')
<!--====== BANNER PART START ======-->
@include('themes.frontend.includes.breadcrumb',['titleClass'=>'text-white'])
<!--====== BANNER PART ENDS ======-->

<!--==================================================-->
<!-----Start contact Section Style Seven ----->
<!--===================================================-->
@if (isset($dataArr['custom_fields']['editor_1']))
    {!!  app(App\Services\ShortcodeProcessor::class)->process($dataArr['custom_fields']['editor_1']['value']) !!}
@endif

<section class="appoinment-form  appointment-page pt-pb-130 ">
  <div class="container">
    <div class="row">
      <div class="col-xl-12">
        <div class="appoinment-box">
          <center>
            <h1>ALLISTON PHYSIOTHERAPY &amp; SPORTS REHABILITATION</h1>
          </center>
          <div class="row">
            <form action="{{ url('health-questionnaire-process') }}" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
              @csrf
              <div class="pq-appointment">
                <div class="row">
                  <div class="col-lg-6  ">Name <span class="required text-danger">*</span>		
                    <input class="form-control pq-bg-white paitent-name-field" id="" name="patient_name" required="required" type="text"   placeholder="Name"   autocomplete="off" value="{{ old('patient_name') }}">
										@error('patient_name') <span class="text-danger">{{ $message }}</span> @enderror
                  </div>                
                  <div class="col-lg-6  ">Date <span class="required text-danger">*</span>		
                    <input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="date" required="required" type="date"   placeholder="Date"   autocomplete="off" value="{{ old('date') }}">
										@error('date') <span class="text-danger">{{ $message }}</span> @enderror
                  </div>
                  <div class="col-lg-6  ">Family Doctor's Name <span class="required text-danger">*</span>		
                    <input class="form-control pq-bg-white paitent-name-field" id="" name="doctor_name"  type="text"   placeholder=""   autocomplete="off" value="{{ old('doctor_name') }}">
										@error('doctor_name') <span class="text-danger">{{ $message }}</span> @enderror
                  </div> 
                  <div class="col-lg-6  ">Doctors Phone No. <span class="required text-danger">*</span>		
                    <input class="form-control pq-bg-white paitent-name-field" id="" name="doctor_phone" type="text"   placeholder=""   autocomplete="off" value="{{ old('doctor_phone') }}">
										@error('doctor_phone') <span class="text-danger">{{ $message }}</span> @enderror
                  </div>
                </div>
                <div class="row">
                  <div class="col-lg-12  ">
                    <strong>1.Do you have any heart problems?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_heart_problems-1" name="new_patient_problems[has_heart_problems]" {{ old('new_patient_problems.has_heart_problems') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_heart_problems-2" name="new_patient_problems[has_heart_problems]" {{ old('new_patient_problems.has_heart_problems') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>2.Do you have any thyroid problems?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_thyroid_problems-1" name="new_patient_problems[has_thyroid_problems]" {{ old('new_patient_problems.has_thyroid_problems') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_thyroid_problems-2" name="new_patient_problems[has_thyroid_problems]" {{ old('new_patient_problems.has_thyroid_problems') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>3.Do you have HIGH or LOW blood pressure?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_high_or_low_blood_pressure-1" name="new_patient_problems[has_high_or_low_blood_pressure]" {{ old('new_patient_problems.has_high_or_low_blood_pressure') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_high_or_low_blood_pressure-2" name="new_patient_problems[has_high_or_low_blood_pressure]" {{ old('new_patient_problems.has_high_or_low_blood_pressure') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>4.Are you currently taking any medications? : </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_taking_any_medications-1" name="new_patient_problems[has_taking_any_medications]" {{ old('new_patient_problems.has_taking_any_medications') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_taking_any_medications-2" name="new_patient_problems[has_taking_any_medications]" {{ old('new_patient_problems.has_taking_any_medications') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <input class="form-control pq-bg-white" id="new_patient_problems-taking_any_medication_list" name="new_patient_problems[taking_any_medication_list]" type="text" placeholder="If yes, please list" autocomplete="off" value="{{ old('new_patient_problems.taking_any_medication_list') }}">
                  </div>
                  <div class="col-lg-12  ">
                    <strong>5.Have you been diagnosed with arthritis?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_diagnosed_with_arthritis-1" name="new_patient_problems[has_diagnosed_with_arthritis]" {{ old('new_patient_problems.has_diagnosed_with_arthritis') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_diagnosed_with_arthritis-2" name="new_patient_problems[has_diagnosed_with_arthritis]" {{ old('new_patient_problems.has_diagnosed_with_arthritis') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>6.Do you have diabetes?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_diabetes-1" name="new_patient_problems[has_diabetes]" {{ old('new_patient_problems.has_diabetes') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_diabetes-2" name="new_patient_problems[has_diabetes]" {{ old('new_patient_problems.has_diabetes') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>7.Do you have or ever had cancer?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_ever_had_cancer-1" name="new_patient_problems[has_ever_had_cancer]" {{ old('new_patient_problems.has_ever_had_cancer') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_ever_had_cancer-2" name="new_patient_problems[has_ever_had_cancer]" {{ old('new_patient_problems.has_ever_had_cancer') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>8.Have you ever broken a bone?:  </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_broken_a_bone-1" name="new_patient_problems[has_broken_a_bone]" {{ old('new_patient_problems.has_broken_a_bone') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_broken_a_bone-2" name="new_patient_problems[has_broken_a_bone]" {{ old('new_patient_problems.has_broken_a_bone') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>9.Do you have any metal fixations, plates, screws, etc.?:  </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_metal_fixations-1" name="new_patient_problems[has_metal_fixations]" {{ old('new_patient_problems.has_metal_fixations') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_metal_fixations-2" name="new_patient_problems[has_metal_fixations]" {{ old('new_patient_problems.has_metal_fixations') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>10.Do you smoke? : </strong>
                    <input type="radio" value="1" id="new_patient_problems-do_you_smoke-1" name="new_patient_problems[do_you_smoke]" {{ old('new_patient_problems.do_you_smoke') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-do_you_smoke-2" name="new_patient_problems[do_you_smoke]" {{ old('new_patient_problems.do_you_smoke') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <input class="form-control pq-bg-white" id="new_patient_problems-smoke_much" name="new_patient_problems[smoke_much]" type="text" placeholder="How Much" autocomplete="off" value="{{ old('new_patient_problems.smoke_much') }}">
                  </div>
                  <div class="col-lg-12  ">
                    <strong>11.Do you have any abdominal problems, ie hernia, ulcer?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_abdominal_problems-1" name="new_patient_problems[has_abdominal_problems]" {{ old('new_patient_problems.has_abdominal_problems') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_abdominal_problems-2" name="new_patient_problems[has_abdominal_problems]" {{ old('new_patient_problems.has_abdominal_problems') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>12.Have you had any previous surgeries : </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_previous_surgeries-1" name="new_patient_problems[has_previous_surgeries]" {{ old('new_patient_problems.has_previous_surgeries') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_previous_surgeries-2" name="new_patient_problems[has_previous_surgeries]" {{ old('new_patient_problems.has_previous_surgeries') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <input class="form-control pq-bg-white" id="new_patient_problems-previous_surgeries_list" name="new_patient_problems[previous_surgeries_list]" type="text" placeholder="Please List" autocomplete="off">
                  </div>
                  <div class="col-lg-12  ">
                    <strong>13.If female, are you or could you be pregnant?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-are_you_pregnant-1" name="new_patient_problems[are_you_pregnant]" {{ old('new_patient_problems.are_you_pregnant') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-are_you_pregnant-2" name="new_patient_problems[are_you_pregnant]" {{ old('new_patient_problems.are_you_pregnant') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>14.Have you been involved in a previous car accident?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_previous_car_accident-1" name="new_patient_problems[has_previous_car_accident]" {{ old('new_patient_problems.has_previous_car_accident') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_previous_car_accident-2" name="new_patient_problems[has_previous_car_accident]" {{ old('new_patient_problems.has_previous_car_accident') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <input class="form-control pq-bg-white date_empty flatpickr-input" id="new_patient_problems-previous_car_accident_date" name="new_patient_problems[previous_car_accident_date]" type="hidden" placeholder="Accident Date" autocomplete="off" value="{{ old('new_patient_problems.previous_car_accident_date') }}">
                    <input class="form-control pq-bg-white date_empty form-control input" placeholder="Accident Date" tabindex="0" type="text" readonly="readonly">
                  </div>
                  <div class="col-lg-12  ">
                    <strong>15.Do you have any allergies, skin irritations, infections, etc?: </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_any_allergies-1" name="new_patient_problems[has_any_allergies]" {{ old('new_patient_problems.has_any_allergies') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_any_allergies-2" name="new_patient_problems[has_any_allergies]" {{ old('new_patient_problems.has_any_allergies') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>16.Do you have asthma or any respiratory problems?:   </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_asthma-1" name="new_patient_problems[has_asthma]" {{ old('new_patient_problems.has_asthma') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_asthma-2" name="new_patient_problems[has_asthma]" {{ old('new_patient_problems.has_asthma') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>17.Do you have any other health problems not listed above?:  </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_other_health_problems-1" name="new_patient_problems[has_other_health_problems]" {{ old('new_patient_problems.has_other_health_problems') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_other_health_problems-2" name="new_patient_problems[has_other_health_problems]" {{ old('new_patient_problems.has_other_health_problems') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-12  ">
                    <strong>18.Is there any other reason that you should not do physical activities?:  </strong>
                    <input type="radio" value="1" id="new_patient_problems-has_any_other_reason-1" name="new_patient_problems[has_any_other_reason]" {{ old('new_patient_problems.has_any_other_reason') == 1 ? 'checked' : '' }}>
                    &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                    <span class="form-control-option">
                      <input type="radio" value="2" id="new_patient_problems-has_any_other_reason-2" name="new_patient_problems[has_any_other_reason]" {{ old('new_patient_problems.has_any_other_reason') == 2 ? 'checked' : '' }}>
                      &nbsp;No
                    </span>
                  </div>
                  <div class="col-lg-6  ">
                    When was your last Physiotherapy visit
                    <input class="form-control pq-bg-white" id="new_patient_forms-last_physiotherapy_visit" name="new_patient_forms[last_physiotherapy_visit]" type="text" placeholder="Last Physiotherapy visit?" autocomplete="off" value="{{ old('new_patient_forms.last_physiotherapy_visit') }}">
                  </div>
                  <div class="col-lg-6  ">
                    Where was your last Physiotherapy visit
                    <input class="form-control pq-bg-white" id="new_patient_forms-last_physiotherapy_location" name="new_patient_forms[last_physiotherapy_location]" type="text" placeholder="Where?" autocomplete="off" value="{{ old('new_patient_forms.last_physiotherapy_location') }}">
                  </div>
                  <div class="col-lg-6  ">
                    Emergency contact person
                    <input class="form-control pq-bg-white" id="new_patient_forms-emergency_contact_person" name="new_patient_forms[emergency_contact_person]" type="text" placeholder="Emergency contact person" autocomplete="off" value="{{ old('new_patient_forms.emergency_contact_person') }}">
                  </div>
                  <div class="col-lg-6  ">
                    Emergency Phone
                    <input class="form-control pq-bg-white" id="new_patient_forms-emergency_phone" name="new_patient_forms[emergency_phone]" type="text" placeholder="Emergency Phone" autocomplete="off" value="{{ old('new_patient_forms.emergency_phone') }}">
                  </div>
                  <div class="col-lg-6  ">
                    Client’s Signature
                    <input class="form-control pq-bg-white" id="new_patient_forms-client_sign" name="new_patient_forms[client_sign]" type="text" placeholder="Client’s Signature" autocomplete="off" value="{{ old('new_patient_forms.client_sign') }}">
                  </div>
                </div>
                <div>
                  <center>
                    <div class="quote_btn pb-4 ">
                      <div class="pq-button-block">
                        <button type="submit" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">Submit Now</button>
                      </div>
                    </div>
                  </center>
                </div>
              </div>
            </form>
            <!-- END: FORM -->
          </div>
        </div>
      </div>
    </div>
  </div>
</section>
@stop