| Patient Name |
: |
{{ $data->patient_name }} |
| Date |
: |
{{ $data->date }} |
| Family Doctor's Name |
: |
{{ $data->doctor_name }} |
| Doctors Phone No |
: |
{{ $data->doctor_phone }} |
| 1.Do you have any heart problems? |
: |
{{ $data->has_heart_problems == 1 ? 'Yes' : 'No' }} |
| 2.Do you have any thyroid problems? |
: |
{{ $data->has_thyroid_problems == 1 ? 'Yes' : 'No' }} |
| 3.Do you have HIGH or LOW blood pressure? |
: |
{{ $data->has_blood_pressure == 1 ? 'Yes' : 'No' }} |
| 4.Are you currently taking any medications? |
: |
{{ $data->taking_medications == 1 ? 'Yes' : 'No' }} |
| If yes, please list |
: |
{{ $data->medication_list }} |
| 5.Have you been diagnosed with arthritis? |
: |
{{ $data->has_arthritis == 1 ? 'Yes' : 'No' }} |
| 6.Do you have diabetes? |
: |
{{ $data->has_diabetes == 1 ? 'Yes' : 'No' }} |
| 7.Do you have or ever had cancer? |
: |
{{ $data->cancer == 1 ? 'Yes' : 'No' }} |
| 8.Have you ever broken a bone? |
: |
{{ $data->has_broken_bone == 1 ? 'Yes' : 'No' }} |
| 9.Do you have any metal fixations, plates, screws, etc.? |
: |
{{ $data->has_metal_fixations == 1 ? 'Yes' : 'No' }} |
| 10.Do you smoke? |
: |
{{ $data->do_you_smoke == 1 ? 'Yes' : 'No' }} |
| How much |
: |
{{ $data->smoke_much }} |
| 11.Do you have any abdominal problems, ie hernia, ulcer? |
: |
{{ $data->has_abdominal_problems == 1 ? 'Yes' : 'No' }} |
| 12.Have you had any previous surgeries |
: |
{{ $data->has_previous_surgeries == 1 ? 'Yes' : 'No' }} |
| Previous surgeries list |
: |
{{ $data->previous_surgeries_list }} |
| 13.If female, are you or could you be pregnant? |
: |
{{ $data->is_pregnant == 1 ? 'Yes' : 'No' }} |
| 14.Have you been involved in a previous car accident? |
: |
{{ $data->has_car_accident == 1 ? 'Yes' : 'No' }} |
| Accident Date |
: |
{{ $data->car_accident_date }} |
| 15.Do you have any allergies, skin irritations, infections, etc? |
: |
{{ $data->has_allergies == 1 ? 'Yes' : 'No' }} |
| 16.Do you have asthma or any respiratory problems? |
: |
{{ $data->asthma == 1 ? 'Yes' : 'No' }} |
| 17.Do you have any other health problems not listed above? |
: |
{{ $data->has_other_health_problems == 1 ? 'Yes' : 'No' }} |
| 18.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 }} |
 }}){kind=logo}