@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

<style>
    input, textarea, select, input.form-control{
        margin-bottom: 15px;
    }
</style>
<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>INSURANCE INFORMATION</h1>
                        <h6 class="text-white">
                            27 Victoria St. East, Alliston, On L9R1T9<br />Tel 705-434-0645 or 705-435-5153 Fax
                            705-435-5754
                        </h6>
                    </center>

                    <div class="row">
                        <form action="#" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
                            @csrf
                            <div class="pq-appointment">
                                <div class="row">
									<div class="col-lg-12 mt-3"><h5 class="text-white">Primary Insurance</h5></div>
                                    <div class="col-lg-4">
                                        INSURANCE NAME:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white paitent-name-field" name="primary_insurance_name" required="required" type="text" placeholder="" autocomplete="off"/>
                                    </div>

                                    <div class="col-lg-4">
                                        MEMBER NAME:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="primary_member_name" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        POLICY NUMBER:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="primary_policy_number" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        CERTIFICATE NUMBER:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="primary_certificate_number" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                       DATE OF BIRTH:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white date" name="primary_dob" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        RELATIONSHIP TO THE PATIENT:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="primary_relationship" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
                                    <div class="col-lg-12 mt-3"><h5 class="text-white">Secondary Insurance</h5></div>
                                    <div class="col-lg-4">
                                        INSURANCE NAME:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white paitent-name-field" name="secondary_insurance_name" required="required" type="text" placeholder="" autocomplete="off"/>
                                    </div>
                                    <div class="col-lg-4">
                                        MEMBER NAME:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="secondary_member_name" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        POLICY NUMBER:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="secondary_policy_number" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        CERTIFICATE NUMBER:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="secondary_certificate_number" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                       DATE OF BIRTH:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white date" name="secondary_dob" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
									<div class="col-lg-4">
                                        RELATIONSHIP TO THE PATIENT:
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="secondary_relationship" required="required" type="text" placeholder="" autocomplete="off"/>                             
                                    </div>
								</div>
                                <div class="row">
                                    <div class="col-lg-12 text-center py-3">
                                        <h5 class="text-white">The Rivermead Post-Concussion Symptoms Questionnaire*</h5>
                                        <p>After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please click the number closest to your answer.</p>
                                    </div>
                                    <div class="col-lg-12">
                                        <table class="rating-table">
                                            <tbody>
                                                <tr>
                                                    <th>Symptom</th>
                                                    <th>0</th>
                                                    <th>1</th>
                                                    <th>2</th>
                                                    <th>3</th>
                                                    <th>4</th>
                                                </tr>
                                                <tr>
                                                    <td>Headaches</td>
                                                    <td><input type="radio" name="headaches" value="0" /></td>
                                                    <td><input type="radio" name="headaches" value="1" /></td>
                                                    <td><input type="radio" name="headaches" value="2" /></td>
                                                    <td><input type="radio" name="headaches" value="3" /></td>
                                                    <td><input type="radio" name="headaches" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Feelings of Dizziness</td>
                                                    <td><input type="radio" name="feelings_of_dizziness" value="0" /></td>
                                                    <td><input type="radio" name="feelings_of_dizziness" value="1" /></td>
                                                    <td><input type="radio" name="feelings_of_dizziness" value="2" /></td>
                                                    <td><input type="radio" name="feelings_of_dizziness" value="3" /></td>
                                                    <td><input type="radio" name="feelings_of_dizziness" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Nausea and/or Vomiting</td>
                                                    <td><input type="radio" name="nausea_and_or_vomiting" value="0" /></td>
                                                    <td><input type="radio" name="nausea_and_or_vomiting" value="1" /></td>
                                                    <td><input type="radio" name="nausea_and_or_vomiting" value="2" /></td>
                                                    <td><input type="radio" name="nausea_and_or_vomiting" value="3" /></td>
                                                    <td><input type="radio" name="nausea_and_or_vomiting" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Noise Sensitivity easily upset by loud noise</td>
                                                    <td><input type="radio" name="noise_sensitivity" value="0" /></td>
                                                    <td><input type="radio" name="noise_sensitivity" value="1" /></td>
                                                    <td><input type="radio" name="noise_sensitivity" value="2" /></td>
                                                    <td><input type="radio" name="noise_sensitivity" value="3" /></td>
                                                    <td><input type="radio" name="noise_sensitivity" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Sleep Disturbance</td>
                                                    <td><input type="radio" name="sleep_disturbance" value="0" /></td>
                                                    <td><input type="radio" name="sleep_disturbance" value="1" /></td>
                                                    <td><input type="radio" name="sleep_disturbance" value="2" /></td>
                                                    <td><input type="radio" name="sleep_disturbance" value="3" /></td>
                                                    <td><input type="radio" name="sleep_disturbance" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Fatigue, tiring more easily</td>
                                                    <td><input type="radio" name="fatigue" value="0" /></td>
                                                    <td><input type="radio" name="fatigue" value="1" /></td>
                                                    <td><input type="radio" name="fatigue" value="2" /></td>
                                                    <td><input type="radio" name="fatigue" value="3" /></td>
                                                    <td><input type="radio" name="fatigue" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Being Irritable, easily angered</td>
                                                    <td><input type="radio" name="irritability" value="0" /></td>
                                                    <td><input type="radio" name="irritability" value="1" /></td>
                                                    <td><input type="radio" name="irritability" value="2" /></td>
                                                    <td><input type="radio" name="irritability" value="3" /></td>
                                                    <td><input type="radio" name="irritability" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Feeling Depressed or Tearful</td>
                                                    <td><input type="radio" name="feeling_depressed_or_tearful" value="0" /></td>
                                                    <td><input type="radio" name="feeling_depressed_or_tearful" value="1" /></td>
                                                    <td><input type="radio" name="feeling_depressed_or_tearful" value="2" /></td>
                                                    <td><input type="radio" name="feeling_depressed_or_tearful" value="3" /></td>
                                                    <td><input type="radio" name="feeling_depressed_or_tearful" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Feeling Frustrated or Impatient</td>
                                                    <td><input type="radio" name="feeling_frustrated" value="0" /></td>
                                                    <td><input type="radio" name="feeling_frustrated" value="1" /></td>
                                                    <td><input type="radio" name="feeling_frustrated" value="2" /></td>
                                                    <td><input type="radio" name="feeling_frustrated" value="3" /></td>
                                                    <td><input type="radio" name="feeling_frustrated" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Forgetfulness, poor memory</td>
                                                    <td><input type="radio" name="forgetfulness" value="0" /></td>
                                                    <td><input type="radio" name="forgetfulness" value="1" /></td>
                                                    <td><input type="radio" name="forgetfulness" value="2" /></td>
                                                    <td><input type="radio" name="forgetfulness" value="3" /></td>
                                                    <td><input type="radio" name="forgetfulness" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Poor Concentration</td>
                                                    <td><input type="radio" name="poor_concentration" value="0" /></td>
                                                    <td><input type="radio" name="poor_concentration" value="1" /></td>
                                                    <td><input type="radio" name="poor_concentration" value="2" /></td>
                                                    <td><input type="radio" name="poor_concentration" value="3" /></td>
                                                    <td><input type="radio" name="poor_concentration" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Taking Longer to Think</td>
                                                    <td><input type="radio" name="taking_longer_to_think" value="0" /></td>
                                                    <td><input type="radio" name="taking_longer_to_think" value="1" /></td>
                                                    <td><input type="radio" name="taking_longer_to_think" value="2" /></td>
                                                    <td><input type="radio" name="taking_longer_to_think" value="3" /></td>
                                                    <td><input type="radio" name="taking_longer_to_think" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Blurred Vision</td>
                                                    <td><input type="radio" name="blurred_vision" value="0" /></td>
                                                    <td><input type="radio" name="blurred_vision" value="1" /></td>
                                                    <td><input type="radio" name="blurred_vision" value="2" /></td>
                                                    <td><input type="radio" name="blurred_vision" value="3" /></td>
                                                    <td><input type="radio" name="blurred_vision" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Light Sensitivity</td>
                                                    <td><input type="radio" name="light_sensitivity" value="0" /></td>
                                                    <td><input type="radio" name="light_sensitivity" value="1" /></td>
                                                    <td><input type="radio" name="light_sensitivity" value="2" /></td>
                                                    <td><input type="radio" name="light_sensitivity" value="3" /></td>
                                                    <td><input type="radio" name="light_sensitivity" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Double Vision Easily upset by bright light</td>
                                                    <td><input type="radio" name="double_vision" value="0" /></td>
                                                    <td><input type="radio" name="double_vision" value="1" /></td>
                                                    <td><input type="radio" name="double_vision" value="2" /></td>
                                                    <td><input type="radio" name="double_vision" value="3" /></td>
                                                    <td><input type="radio" name="double_vision" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Restlessness</td>
                                                    <td><input type="radio" name="restlessness" value="0" /></td>
                                                    <td><input type="radio" name="restlessness" value="1" /></td>
                                                    <td><input type="radio" name="restlessness" value="2" /></td>
                                                    <td><input type="radio" name="restlessness" value="3" /></td>
                                                    <td><input type="radio" name="restlessness" value="4" /></td>
                                                </tr>
                                                <tr>
                                                    <td colspan="6" class="text-start ">Are you experiencing any other difficulties?</td>
                                                </tr>
                                                <tr>
                                                    <td><input class="form-control pq-bg-white mb-0" name="other_difficulties_text"/></td>
                                                    <td><input type="radio" name="other_difficulties_value" value="0" /></td>
                                                    <td><input type="radio" name="other_difficulties_value" value="1" /></td>
                                                    <td><input type="radio" name="other_difficulties_value" value="2" /></td>
                                                    <td><input type="radio" name="other_difficulties_value" value="3" /></td>
                                                    <td><input type="radio" name="other_difficulties_value" value="4" /></td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-12 text-center py-3">
                                        <h5 class="text-white">Initial Concussion Patient Interview</h5>
                                    </div>
                                    <div class="col-lg-4">
                                        Patient Name
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="patient_name" required="required" type="text" placeholder="" autocomplete="off"/>
                                    </div>
                                     <div class="col-lg-4">
                                        Date of Injury
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white date" name="date_of_injury" required="required" type="text" placeholder="" autocomplete="off"/>
                                    </div>
                                     <div class="col-lg-4">
                                        Date of Assessment
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white date" name="date_of_assessment" required="required" type="text" placeholder="" autocomplete="off"/>
                                    </div>
                                    <div class="col-lg-12">
                                        <h5 class="text-white">Referral Signs</h5>
                                    </div>
                                    <div class="col-lg-12">
                                        <div class="checkbox-grid">
                                            <label><input type="checkbox" name="referral_signs[]" value="Worsening Headache" /> Worsening Headache</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Unusual Confusion" /> Unusual Confusion</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Grossly Unusual Behavior" /> Grossly Unusual Behavior</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Progressive Neuro Decline" /> Progressive Neuro Decline</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Recent Fever/Infection" /> Recent Fever/Infection</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Slurred Speech" /> Slurred Speech</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Seizure" /> Seizure</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Unsteadiness" /> Unsteadiness</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Excessive Drowsiness" /> Excessive Drowsiness</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Repeated Nausea/Vomiting" /> Repeated Nausea/Vomiting</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Fluctuating Consciousness" /> Fluctuating Consciousness</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Reported Double Vision" /> Reported Double Vision</label>
                                            <label><input type="checkbox" name="referral_signs[]" value="Constant Blurred Vision" /> Constant Blurred Vision</label>
                                        </div>
                                    </div>
                                     <div class="col-lg-12">
                                        Mechanism of Injury:
                                        <textarea name="mechanism_of_injury"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                       <input type="checkbox" name="direct_head_contact" value="Direct Head Contact">Direct Head Contact 
                                       <input type="checkbox" name="indirect_whiplash" value="InDirect(whiplash)">InDirect(whiplash)
                                    </div>
                                    <div class="col-lg-12">
                                        Early Symptoms Experienced:
                                        <textarea name="early_symptoms_experienced"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        Relevant Medical Follow Ups, Specialists /Evaluations
                                        <textarea name="specialists_evaluations"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        Imaging, Special Testing, New Medications:
                                        <textarea name="imaging_special_testing"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        Occupation at time of Injury:
                                        <textarea name="occupation_at_time_of_injury"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        Current Work/Academic Load:
                                        <div class="checkbox-grid">
                                            <label><input type="checkbox" name="current_work_academic_load[]" value="Off work/school" /> Off work/school</label>
                                            <label><input type="checkbox" name="current_work_academic_load[]" value="Modified/Part-time" /> Modified/Part-time</label>
                                            <label><input type="checkbox" name="current_work_academic_load[]" value="Full time/demands" /> Full time/demands</label> 
                                        </div>
                                    </div>
                                    <div class="col-lg-12">
                                        Current/Ongoing Symptoms and Functional Limitations:
                                        <div class="checkbox-grid" style="display:block;">
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Head Pressure" /> 
                                                Head Pressure
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Dizziness" /> Dizziness</label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Lightheaded with Position Change" /> 
                                                Lightheaded with Position Change
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Ligh/Noise Sensitivity" /> 
                                                Ligh/Noise Sensitivity
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Eye Fatigue, or Visual Discomfort" /> 
                                                Eye Fatigue, or Visual Discomfort
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Difficulty Reading, Using Screens" /> 
                                                Difficulty Reading, Using Screens
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Sleep Challenges" /> 
                                                Sleep Challenges
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Intolerance to busy places or patterns" /> 
                                                Intolerance to busy places or patterns 
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Mental Fog/Cognitive Challenges" /> 
                                                Mental Fog/Cognitive Challenges
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Driving (Passenger vs Driving)" /> 
                                                Driving (Passenger vs Driving)
                                            </label>
                                            <label>
                                                <input type="checkbox" name="current_ongoing_symptoms_and_functional_limitations[]" value="Mood Challenges" /> 
                                                Mood Challenges
                                            </label>
                                        </div>
                                    </div>
                                    <div class="col-lg-12">
                                        Notes/other:
                                        <textarea name="notes_other"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        History of Concussion or Head/Neck Traum
                                        <textarea name="history_of_concussion"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        Relevant Medical History (Cardio/Neuro/Metabolic/Respiratory)
                                        <textarea name="relevant_medical_history"></textarea>
                                    </div>
                                    <div class="col-lg-12">
                                        <h5 class="text-white">Health History Screening Questions</h5>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <strong>Headache/Migraine History Pre-Concussion </strong>						
                                        <input type="radio" value="1" name="headache_migraine_history_pre_concussion">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" value="0" name="headache_migraine_history_pre_concussion">
                                            &nbsp;No
                                        </span>
                                    </div> 
                                    <div class="col-lg-12">
                                        <input class="form-control pq-bg-white" name="headache_migraine_history_pre_concussion_if_yes" type="text" placeholder="If, Yes" value="">
                                    </div>
                                    <div class="col-lg-12 ">
                                        <strong>Pre-Injury Anxiety/Depression? </strong>						
                                        <input type="radio" value="1" name="pre_injury_anxiety_depression">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" value="0" name="pre_injury_anxiety_depression">
                                            &nbsp;No
                                        </span>
                                    </div> 
                                    <div class="col-lg-12">
                                        <input class="form-control pq-bg-white" name="pre_injury_anxiety_depression_if_yes" type="text" placeholder="If, Yes" value="">
                                    </div>
                                    <div class="col-lg-12 ">
                                        <strong>Hx of Learning Disability? </strong>						
                                        <input type="radio" value="1" name="hx_of_learning_disability">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" value="0" name="hx_of_learning_disability">
                                            &nbsp;No
                                        </span>
                                    </div> 
                                    <div class="col-lg-12">
                                        <input class="form-control pq-bg-white" name="hx_of_learning_disability_if_yes" type="text" placeholder="If, Yes" value="">
                                    </div>
                                    <div class="col-lg-12 ">
                                        <strong>Any Known Vestibular Hx? </strong>						
                                        <input type="radio" value="1" name="any_known_vestibular_hx">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" value="0" name="any_known_vestibular_hx">
                                            &nbsp;No
                                        </span>
                                    </div> 
                                    <div class="col-lg-12">
                                        <input class="form-control pq-bg-white" name="any_known_vestibular_hx_if_yes" type="text" placeholder="If, Yes" value="">
                                    </div>
                                    <div class="col-lg-12 ">
                                        <strong>Hx Motion Sickness? </strong>						
                                        <input type="radio" value="1" name="hx_motion_sickness">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" value="0" name="hx_motion_sickness">
                                            &nbsp;No
                                        </span>
                                    </div> 
                                    <div class="col-lg-12">
                                        <input class="form-control pq-bg-white" name="hx_motion_sickness_if_yes" type="text" placeholder="If, Yes" value="">
                                    </div>
                                    <div class="col-lg-12">
                                        Additional Notes
                                        <textarea name="additional_notes"></textarea>
                                    </div>
                                    <div class="col-lg-12 py-3">
                                        <h4>Clinical Evaluation P1</h4>
                                    </div>
                                    <div class="col-lg-6">
                                        <table class="rating-table">
                                            <tbody>
                                                <tr>
                                                    <th>CRANIAL NERVE SCREEN</th>
                                                    <th>Clear</th>
                                                    <th>Abn.</th>
                                                </tr>
                                                <tr>
                                                    <td>CN I (olfactory)</td>
                                                    <td><input type="radio" name="cn_i_olfactory" value="1" /></td>
                                                    <td><input type="radio" name="cn_i_olfactory" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN II (visual fields,pupiIlary reflex) </td>
                                                    <td><input type="radio" name="cn_ii_visual_fields_pupillary_reflex" value="1" /></td>
                                                    <td><input type="radio" name="cn_ii_visual_fields_pupillary_reflex" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN III(H Pattern)</td>
                                                    <td><input type="radio" name="cn_iii_h_pattern" value="1" /></td>
                                                    <td><input type="radio" name="cn_iii_h_pattern" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN IV(SO - lat/inf)</td>
                                                    <td><input type="radio" name="cn_iv_so_lat_inf" value="1" /></td>
                                                    <td><input type="radio" name="cn_iv_so_lat_inf" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN V(Sensory/mastication mm)</td>
                                                    <td><input type="radio" name="cn_v_sensory_mastication_mm" value="1" /></td>
                                                    <td><input type="radio" name="cn_v_sensory_mastication_mm" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN VI(LR-lat)</td>
                                                    <td><input type="radio" name="cn_vi_lr_lat" value="1" /></td>
                                                    <td><input type="radio" name="cn_vi_lr_lat" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN VII(facial expression mm)</td>
                                                    <td><input type="radio" name="cn_vii_facial_expression_mm" value="1" /></td>
                                                    <td><input type="radio" name="cn_vii_facial_expression_mm" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CNVIII (nystag, whisper)</td>
                                                    <td><input type="radio" name="cn_viii_nystag_whisper" value="1" /></td>
                                                    <td><input type="radio" name="cn_viii_nystag_whisper" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN IX(taste/posteriortongue)</td>
                                                    <td><input type="radio" name="cn_ix_taste_posterior_tongue" value="1" /></td>
                                                    <td><input type="radio" name="cn_ix_taste_posterior_tongue" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN X(uvula, swallow, vocal cords)</td>
                                                    <td><input type="radio" name="cn_x_uvula_swallow_vocal_cords" value="1" /></td>
                                                    <td><input type="radio" name="cn_x_uvula_swallow_vocal_cords" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN IX(Trap,SCM) </td>
                                                    <td><input type="radio" name="cn_xi_trap_scm" value="1" /></td>
                                                    <td><input type="radio" name="cn_xi_trap_scm" value="0" /></td>
                                                </tr>
                                                <tr>
                                                    <td>CN IX(tongue mm, articulation)</td>
                                                    <td><input type="radio" name="cn_xii_tongue_mm_articulation" value="1" /></td>
                                                    <td><input type="radio" name="cn_xii_tongue_mm_articulation" value="0" /></td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-6">
                                        <b>GROSS NEUROVASCULAR </b>
                                        <div class="row">
                                            <div class="col-lg-12 ">
                                                <strong> Cerebellar Signs? </strong>						
                                                <input type="radio" value="1" name="cerebellar_signs">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" value="0" name="cerebellar_signs">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12 ">
                                                <strong>UMN Signs? </strong>						
                                                <input type="radio" value="1" name="umn_signs">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" value="0" name="umn_signs">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12 ">
                                                <strong>Sensory Changes? </strong>						
                                                <input type="radio" value="1" name="sensory_changes">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" value="0" name="sensory_changes">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12 ">
                                                <strong>Myotome Weakness? </strong>						
                                                <input type="radio" value="1" name="myotome_weakness">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" value="0" name="myotome_weakness">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12">
                                                <input class="form-control pq-bg-white" name="dtrs" type="text" placeholder="DTRs" value="">
                                            </div>
                                            <div class="col-lg-12 ">
                                                <strong>Vast </strong>						
                                                <input type="radio" value="1" name="vast">
                                                &nbsp;Neg &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" value="0" name="vast">
                                                    &nbsp;Pos
                                                </span>
                                            </div> 
                                            <div class="col-lg-12">
                                                <input class="form-control pq-bg-white" name="5ds_3ns_list" type="text" placeholder="5D's, 3N's(list)" value="">
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <h6 class="text-white">Vestibular & Oculomotor Screen</h6>
                                    </div>
                                    <div class="col-lg-12">
                                        <table class="medical-table">
                                            <tbody>
                                                <tr>
                                                    <td>Gaze Fixation</td>
                                                    <td>
                                                        <label><input type="radio" name="gaze_fixation_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="gaze_fixation_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="gaze_fixation_2" value="Poor Fixation (Sign)" /> Poor Fixation (Sign)</label>
                                                        <label><input type="radio" name="gaze_fixation_2" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="gaze_fixation_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>NPC</td>
                                                    <td>
                                                        <label><input type="radio" name="npc_1" value="Normal NPC X3 < 6cm" /> Normal NPC X3 < 6cm</label> 
                                                        <label><input type="radio" name="npc_1" value="Abnormal / Remote NPC" /> Abnormal / Remote NPC</label>
                                                        <label><input type="radio" name="npc_1" value="Abnormal Recovery > 3-4cm" /> Abnormal Recovery > 3-4cm</label>
                                                    </td>
                                                    <td>
                                                        <div class="npc-grid">
                                                            <input type="text" placeholder="Break 1" name="npc_2">
                                                            <input type="text" placeholder="Break 2" name="npc_3">
                                                            <input type="text" placeholder="Break 3" name="npc_4">
                                                        </div>
                                                        <label><input type="radio" name="npc_5" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="npc_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Accommodation</td>
                                                    <td>
                                                        <label><input type="radio" name="accommodation" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="accommodation" value="Abnormal" /> Abnormal Amps (for age)</label>
                                                    </td>
                                                    <td><textarea placeholder="Notes" name="accommodation_notes"></textarea></td>
                                                </tr>
                                                <tr>
                                                    <td>Pursuits</td>
                                                    <td>
                                                        <label><input type="radio" name="pursuits_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="pursuits_1" value="Abnormal Horiz" /> Abnormal Horiz</label>
                                                        <label><input type="radio" name="pursuits_1" value="Abnormal Vert" /> Abnormal Vert</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="pursuits_2" value="Nystagmus" /> Nystagmus</label>
                                                        <label><input type="radio" name="pursuits_2" value="Saccadic Movement" /> Saccadic Movement</label>
                                                        <label><input type="radio" name="pursuits_2" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="pursuits_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Saccades</td>
                                                    <td>
                                                        <label><input type="radio" name="saccades_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="saccades_1" value="Abnormal Horiz" /> Abnormal Horiz</label>
                                                        <label><input type="radio" name="saccades_1" value="Abnormal Vert" /> Abnormal Vert</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="saccades_2" value="Undershoot/Overshoot" /> Undershoot/Overshoot</label>
                                                        <label><input type="radio" name="saccades_2" value="Difficult/Slow/Pauses" /> Difficult/Slow/Pauses</label>
                                                        <label><input type="radio" name="saccades_2" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="saccades_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>VOR (180 bpm)</td>
                                                    <td>
                                                        <label><input type="radio" name="vor_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="vor_1" value="Abnormal Horiz" /> Abnormal Horiz</label>
                                                        <label><input type="radio" name="vor_1" value="Abnormal Vert" /> Abnormal Vert</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="vor_2" value="Does not maintain fixation" /> Does not maintain fixation</label>
                                                        <label><input type="radio" name="vor_2" value="Unable to keep target in focus" /> Unable to keep target in focus</label>
                                                        <label><input type="radio" name="vor_2" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="vor_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>VMS (50 bpm)</td>
                                                    <td>
                                                        <label><input type="radio" name="vms_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="vms_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="vms_2" value="Does not maintain fixation" /> Does not maintain fixation</label>
                                                        <label><input type="radio" name="vms_2" value="Symptoms" /> ↑ Symptoms</label>
                                                        <input type="text" name="vms_symptoms" placeholder="Symptoms">
                                                    </td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-12">
                                        <h4>Clinical Evaluation P2</h4>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <h6 class="text-white">Special Testing (If Indicated)</h6>
                                    </div>
                                    <div class="col-lg-12">
                                        <table class="medical-table">
                                            <tbody>
                                                <tr>
                                                    <td>Head Thrust Test</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_head_thrust_test" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_head_thrust_test" value="Abn R" /> Abn R</label>
                                                        <label><input type="radio" name="special_testing_head_thrust_test" value="Abn L" /> Abn L</label>
                                                    </td>
                                                    <td></td>
                                                </tr>
                                                <tr>
                                                    <td>Dynamic Visual Acuity</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_dynamic_visual_acuity" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_dynamic_visual_acuity" value="Abnormal (>=2 lines)" /> Abnormal (>=2 lines)</label>
                                                    </td>
                                                    <td><input type="text" placeholder="# Lines Difference" name="special_testing_dynamic_visual_acuity_text" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Dix Hallpike</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_dix_hallpike" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_dix_hallpike" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td><input type="text" placeholder="Nystagm. Pattern" name="special_testing_dix_hallpike_text" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Lateral Pos/Head Roll</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_lateral_pos_head_roll" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_lateral_pos_head_roll" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td><input type="text" placeholder="Nystagm. Pattern" name="special_testing_lateral_pos_head_roll_text" /></td>
                                                </tr>
                                                <tr>
                                                    <td>Visual Fields (confrontation)</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_visual_fields_confrontation_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_visual_fields_confrontation_1" value="Reduced" /> Reduced</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_visual_fields_confrontation_2" value="Generalized" /> Generalized</label>
                                                        <label><input type="radio" name="special_testing_visual_fields_confrontation_2" value="Pattern Specific" /> Pattern Specific</label>
                                                        <input type="text" name="special_testing_visual_fields_confrontation_text" />
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Other</td>
                                                    <td>
                                                        <label><input type="radio" name="special_testing_other" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="special_testing_other" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td></td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <h6 class="text-white">Balance And Gait</h6>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <table class="medical-table">
                                            <tbody>
                                                <tr>
                                                    <td>Normal Gait</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_normal_gait_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_normal_gait_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_normal_gait_2" value="Unstable/Abnormal Pattern" /> Unstable/Abnormal Pattern</label>
                                                        <label><input type="radio" name="balance_and_gait_normal_gait_2" value="Unilateral Drift R L" /> Unilateral Drift R L</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Tandem Gait (fwd, bkwd)<br>Eyes open, 5 steps*</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_2" value="Fall/Unstable/Overstep" /> Fall/Unstable/Overstep</label>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_2" value="Unilateral Drift R L" /> Unilateral Drift R L</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Tandem Gait (fwd, bkwd)<br>Eyes closed, 5 steps*</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_2" value="Fall/Unstable/Overstep" /> Fall/Unstable/Overstep</label>
                                                        <label><input type="radio" name="balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_2" value="Unilateral Drift R L" /> Unilateral Drift R L</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Balance: Feet together (Firm)<br>Eyes closed (20s)*</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_firm_eyes_closed_20s_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_firm_eyes_closed_20s_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2" value="Fall Out of Position" /> Fall Out of Position</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2" value="Sway" /> ↑ Sway</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2" value="Symptoms (Dizzy)" /> ↑ Symptoms (Dizzy)</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Balance: Semi Tandem (Firm)<br>Eyes closed (20s)*</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2" value="Fall Out of Position" /> Fall Out of Position</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2" value="Sway" /> ↑ Sway</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2" value="Symptoms (Dizzy)" /> ↑ Symptoms (Dizzy)</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Balance: Feet Together (Foam)<br>Eyes closed (20s)*</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_foam_eyes_closed_20s_1" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_foam_eyes_closed_20s_1" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2" value="Fall Out of Position" /> Fall Out of Position</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2" value="Sway" /> ↑ Sway</label>
                                                        <label><input type="radio" name="balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2" value="Symptoms (Dizzy)" /> ↑ Symptoms (Dizzy)</label>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Others</td>
                                                    <td>
                                                        <label><input type="radio" name="balance_and_gait_others" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="balance_and_gait_others" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        
                                                    </td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-12">
                                        <h4>Clinical Evaluation P3</h4>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <h6 class="text-white">Cervical/Ortho Screen</h6>
                                    </div>
                                    <div class="col-lg-12 ">
                                        <table class="medical-table">
                                            <tbody>
                                                <tr>
                                                    <td>Upper Cervical Ligs</td>
                                                    <td>
                                                        <label><input type="radio" name="cervical_ortho_screen_upper_cervical_ligs" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="cervical_ortho_screen_upper_cervical_ligs" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <textarea name="cervical_ortho_screen_upper_cervical_ligs_text" placeholder="Notes"></textarea>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>
                                                        <b>Range Of Motions</b>
                                                        <br>Flexion(5d)
                                                        <br>Extension (60d)
                                                        <br>Right Lateral Flexion (40-45d)
                                                        <br>Left Lateral Flexion (40-45d)
                                                        <br>Right Rotation (80d)
                                                        <br>Left Rotation (80d)
                                                    </td>
                                                    <td>
                                                        <br>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_flexion_5d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_flexion_5d" value="Reduced" /> Reduced
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_extension_60d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_extension_60d" value="Reduced" /> Reduced
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_right_lateral_flexion_40_45d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_right_lateral_flexion_40_45d" value="Reduced" /> Reduced
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_left_lateral_flexion_40_45d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_left_lateral_flexion_40_45d" value="Reduced" /> Reduced
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_right_rotation_80d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_right_rotation_80d" value="Reduced" /> Reduced
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_left_rotation_80d" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_left_rotation_80d" value="Reduced" /> Reduced
                                                        </div>
                                                    </td>
                                                    <td>
                                                        <textarea name="cervical_ortho_screen_range_of_motion_text" placeholder="Notes"></textarea>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>
                                                        <b>Joint Tenderness</b>
                                                        <br>Upper Cervical (C1-3)
                                                        <br>Lower Cervical (C4-7)
                                                    </td>
                                                    <td>
                                                        <br>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_upper_cervical_c1_3" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_upper_cervical_c1_3" value="Pain/Restriction" /> Pain/Restriction
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_lower_cervical_c4_7" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_lower_cervical_c4_7" value="Pain/Restriction" /> Pain/Restriction
                                                        </div>
                                                    </td>
                                                    <td>
                                                        <textarea name="cervical_ortho_screen_joint_tenderness_text" placeholder="Notes"></textarea>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>
                                                        <b>Myofascial Tone/Tenderness </b>
                                                        <br>Suboccipital
                                                        <br>Other
                                                    </td>
                                                    <td>
                                                        <br>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_suboccipital" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_suboccipital" value="Pain/Restriction" /> Pain/Restriction
                                                        </div>
                                                        <div class="flex">
                                                            <input type="radio" name="cervical_ortho_screen_other" value="Normal" /> Normal 
                                                            <input type="radio" name="cervical_ortho_screen_other" value="Pain/Restriction" /> Pain/Restriction
                                                        </div>
                                                    <td>
                                                        <textarea name="cervical_ortho_screen_myofascial_tone_tenderness_text" placeholder="Notes"></textarea>
                                                    </td>
                                                </tr>
                                                <tr>
                                                    <td>Special Testing (eg. C-Flex/Rot; <br>Comp/Spurl/DNF/N.Torsion/Rotary stool):</td>
                                                    <td>
                                                        <label><input type="radio" name="cervical_ortho_screen_special_testing_c_flex_rot" value="Normal" /> Normal</label>
                                                        <label><input type="radio" name="cervical_ortho_screen_special_testing_c_flex_rot" value="Abnormal" /> Abnormal</label>
                                                    </td>
                                                    <td>
                                                        <textarea name="cervical_ortho_screen_special_testing_c_flex_rot_text" placeholder="Notes"></textarea>
                                                    </td>
                                                </tr>
                                            </tbody>
                                        </table>
                                    </div>
                                    <div class="col-lg-12">
                                        Clin Impression
                                        <input class="form-control pq-bg-white" name="clin_impression" required="required" type="text" placeholder="">
                                    </div>
                                    <div class="col-lg-12">
                                        Trajectories<br>
                                        <input type="checkbox" name="trajectories[]" value="Vest / Oc"> Vest / Oc
										<input type="checkbox" name="trajectories[]" value="Cervical"> Cervical
										<input type="checkbox" name="trajectories[]" value="PTM"> PTM
										<input type="checkbox" name="trajectories[]" value="Mood"> Mood
										<input type="checkbox" name="trajectories[]" value="Physiol"> Physiol
                                    </div>
                                    <div class="col-lg-6">
                                        Referrals
                                        <input class="form-control pq-bg-white" name="referrals" required="required" type="text" placeholder="">
                                    </div>
                                    <div class="col-lg-6">
                                        POM
                                        <input class="form-control pq-bg-white" name="pom" required="required" type="text" placeholder="">
                                    </div>
                                    <div class="col-lg-6">
                                        Tests to Perform<br>
                                        <input type="checkbox" name="tests_to_perform[]" value="BCTT"> BCTT
										<input type="checkbox" name="tests_to_perform[]" value="Exertion 2"> Exertion 2
										<input type="checkbox" name="tests_to_perform[]" value="Exertion 3"> Exertion 3
                                    </div>
                                    <div class="col-lg-6">
                                        Rehab to Initiate:<br>
                                        <input type="checkbox" name="rehab_to_initiate[]" value="P1 VesVoc"> P1 VesVoc
										<input type="checkbox" name="rehab_to_initiate[]" value="Early Cervical (ROM, Motor Recruitment)"> Early Cervical (ROM, Motor Recruitment)
										<input type="checkbox" name="rehab_to_initiate[]" value="Others"> Others
                                    </div>
                                    <div class="col-lg-12">
                                        If Others
                                        <input class="form-control pq-bg-white" name="rehab_to_initiate_if_others" required="required" type="text" placeholder="">
                                    </div>
                                    <div class="col-lg-12 ">
						                <strong>Patient Aware Care to be shared w/ Kin and Consents? </strong>						
	                                    <input type="radio" value="1" name="patient_aware_care_to_be_shared_w_kin_and_consents">
                                        &nbsp;Yes 
                                    </div>
                                    <div class="col-lg-4">
                                        Name
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="name" required="required" type="text" placeholder="" autocomplete="off">
                                    </div>
                                    <div class="col-lg-4">
                                        Signature
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white" name="patient_signature" required="required" type="text" placeholder="" autocomplete="off">
                                    </div>
                                    <div class="col-lg-4">
                                        Date
                                        <span class="required text-danger">*</span>
                                        <input class="form-control pq-bg-white date" name="patient_date" required="required" type="text" placeholder="" autocomplete="off">
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="col-lg-12">
                                        <center>
                                            <div class="quote_btn pb-4">
                                                <div class="pq-button-block">
                                                    <button type="button" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">
                                                        Submit Now
                                                    </button>
                                                </div>
                                            </div>
                                        </center>
                                    </div>
                                </div>
                            </div>
                        </form>
                        <!-- END: FORM -->
                    </div>
                </div>
            </div>
        </div>
    </div>
</section>
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@stop