1.Do you have any heart problems?:
Yes
No
@php
$heartProblems = old('new_patient_problems.heart_problems', $heartProblems ?? ['']);
@endphp
@foreach($heartProblems as $index => $problem)
@if($index == 0)
@else
@endif
@endforeach
2.Do you have any thyroid problems?:
Yes
No
3.Do you have HIGH or LOW blood pressure?:
Yes
No
4.Are you currently taking any medications? :
Yes
No
5.Have you been diagnosed with arthritis?:
Yes
No
6.Do you have diabetes?:
Yes
No
7.Do you have or ever had cancer?:
Yes
No
8.Have you ever broken a bone?:
Yes
No
9.Do you have any metal fixations, plates, screws, etc.?:
Yes
No
10.Do you smoke? :
Yes
No
11.Do you have any abdominal problems, ie hernia, ulcer?:
Yes
No
12.Have you had any previous surgeries :
Yes
No
13.If female, are you or could you be pregnant?:
Yes
No
14.Have you been involved in a previous car accident?:
Yes
No
15.Do you have any allergies, skin irritations, infections, etc?:
Yes
No
16.Do you have asthma or any respiratory problems?:
Yes
No
17.Do you have any other health problems not listed above?:
Yes
No
18.Is there any other reason that you should not do physical activities?:
Yes
No
When was your last Physiotherapy visit
Where was your last Physiotherapy visit
Emergency contact person
Emergency Phone
Client’s Signature