Authorization PDF Form

Primary Insurance
Insurance Name	{{ $data->primary_insurance_name }}
Member Name	{{ $data->primary_member_name }}
Policy Number	{{ $data->primary_policy_number }}
Certificate Number	{{ $data->primary_certificate_number }}
Date of Birth	{{ $data->primary_dob }}
Relationship to the patient	{{ $data->primary_relationship }}
Secondary Insurance
Insurance Name	{{ $data->secondary_insurance_name }}
Member Name	{{ $data->secondary_member_name }}
Policy Number	{{ $data->secondary_policy_number }}
Certificate Number	{{ $data->secondary_certificate_number }}
Date of Birth	{{ $data->secondary_dob }}
Relationship to the patient	{{ $data->secondary_relationship }}

@if($data->other_difficulties_text) @endif

Symptom	0	1	2	3	4
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.
Headaches	headaches == 0 ? 'checked' : '' }}>	headaches == 1 ? 'checked' : '' }}>	headaches == 2 ? 'checked' : '' }}>	headaches == 3 ? 'checked' : '' }}>	headaches == 4 ? 'checked' : '' }}>
Feelings of Dizziness	feelings_of_dizziness == 0 ? 'checked' : '' }}>	feelings_of_dizziness == 1 ? 'checked' : '' }}>	feelings_of_dizziness == 2 ? 'checked' : '' }}>	feelings_of_dizziness == 3 ? 'checked' : '' }}>	feelings_of_dizziness == 4 ? 'checked' : '' }}>
Nausea and/or Vomiting	nausea_and_or_vomiting == 0 ? 'checked' : '' }}>	nausea_and_or_vomiting == 1 ? 'checked' : '' }}>	nausea_and_or_vomiting == 2 ? 'checked' : '' }}>	nausea_and_or_vomiting == 3 ? 'checked' : '' }}>	nausea_and_or_vomiting == 4 ? 'checked' : '' }}>
Noise Sensitivity easily upset by loud noise	noise_sensitivity == 0 ? 'checked' : '' }}>	noise_sensitivity == 1 ? 'checked' : '' }}>	noise_sensitivity == 2 ? 'checked' : '' }}>	noise_sensitivity == 3 ? 'checked' : '' }}>	noise_sensitivity == 4 ? 'checked' : '' }}>
Sleep Disturbance	sleep_disturbance == 0 ? 'checked' : '' }}>	sleep_disturbance == 1 ? 'checked' : '' }}>	sleep_disturbance == 2 ? 'checked' : '' }}>	sleep_disturbance == 3 ? 'checked' : '' }}>	sleep_disturbance == 4 ? 'checked' : '' }}>
Fatigue, tiring more easily	fatigue == 0 ? 'checked' : '' }}>	fatigue == 1 ? 'checked' : '' }}>	fatigue == 2 ? 'checked' : '' }}>	fatigue == 3 ? 'checked' : '' }}>	fatigue == 4 ? 'checked' : '' }}>
Being Irritable, easily angered	irritability == 0 ? 'checked' : '' }}>	irritability == 1 ? 'checked' : '' }}>	irritability == 2 ? 'checked' : '' }}>	irritability == 3 ? 'checked' : '' }}>	irritability == 4 ? 'checked' : '' }}>
Feeling Depressed or Tearful	feeling_depressed_or_tearful == 0 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 1 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 2 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 3 ? 'checked' : '' }}>	feeling_depressed_or_tearful == 4 ? 'checked' : '' }}>
Feeling Frustrated or Impatient	feeling_frustrated == 0 ? 'checked' : '' }}>	feeling_frustrated == 1 ? 'checked' : '' }}>	feeling_frustrated == 2 ? 'checked' : '' }}>	feeling_frustrated == 3 ? 'checked' : '' }}>	feeling_frustrated == 4 ? 'checked' : '' }}>
Forgetfulness, poor memory	forgetfulness == 0 ? 'checked' : '' }}>	forgetfulness == 1 ? 'checked' : '' }}>	forgetfulness == 2 ? 'checked' : '' }}>	forgetfulness == 3 ? 'checked' : '' }}>	forgetfulness == 4 ? 'checked' : '' }}>
Poor Concentration	poor_concentration == 0 ? 'checked' : '' }}>	poor_concentration == 1 ? 'checked' : '' }}>	poor_concentration == 2 ? 'checked' : '' }}>	poor_concentration == 3 ? 'checked' : '' }}>	poor_concentration == 4 ? 'checked' : '' }}>
Taking Longer to Think	taking_longer_to_think == 0 ? 'checked' : '' }}>	taking_longer_to_think == 1 ? 'checked' : '' }}>	taking_longer_to_think == 2 ? 'checked' : '' }}>	taking_longer_to_think == 3 ? 'checked' : '' }}>	taking_longer_to_think == 4 ? 'checked' : '' }}>
Blurred Vision	blurred_vision == 0 ? 'checked' : '' }}>	blurred_vision == 1 ? 'checked' : '' }}>	blurred_vision == 2 ? 'checked' : '' }}>	blurred_vision == 3 ? 'checked' : '' }}>	blurred_vision == 4 ? 'checked' : '' }}>
Light Sensitivity	light_sensitivity == 0 ? 'checked' : '' }}>	light_sensitivity == 1 ? 'checked' : '' }}>	light_sensitivity == 2 ? 'checked' : '' }}>	light_sensitivity == 3 ? 'checked' : '' }}>	light_sensitivity == 4 ? 'checked' : '' }}>
Double Vision Easily upset by bright light	double_vision == 0 ? 'checked' : '' }}>	double_vision == 1 ? 'checked' : '' }}>	double_vision == 2 ? 'checked' : '' }}>	double_vision == 3 ? 'checked' : '' }}>	double_vision == 4 ? 'checked' : '' }}>
Restlessness	restlessness == 0 ? 'checked' : '' }}>	restlessness == 1 ? 'checked' : '' }}>	restlessness == 2 ? 'checked' : '' }}>	restlessness == 3 ? 'checked' : '' }}>	restlessness == 4 ? 'checked' : '' }}>
Are you experiencing any other difficulties?
	other_difficulties_value == 0 ? 'checked' : '' }}>	other_difficulties_value == 1 ? 'checked' : '' }}>	other_difficulties_value == 2 ? 'checked' : '' }}>	other_difficulties_value == 3 ? 'checked' : '' }}>	other_difficulties_value == 4 ? 'checked' : '' }}>

Patient Name

Date of Injury

Date of Assessment

Referral Signs

@if($data->referral_signs) @php $referral_signs = explode(',', $data->referral_signs); @endphp @for($i = 0; $i < count($referral_signs); $i += 2) @endfor

• {{ trim($referral_signs[$i]) }}

{{ isset($referral_signs[$i+1]) ? '• '.trim($referral_signs[$i+1]) : '' }}

@endif

Mechanism of Injury
direct_head_contact == 'Direct Head Contact' ? 'checked' : '' }}> Direct Head Contact indirect_whiplash == 'InDirect(whiplash)' ? 'checked' : '' }}> InDirect(whiplash)

Early Symptoms Experienced:

Relevant Medical Follow Ups, Specialists /Evaluations

Imaging, Special Testing, New Medications

Occupation at time of Injury

Current Work/Academic Load

@if($data->current_work_academic_load) @php $current_work_academic_load = explode(',',$data->current_work_academic_load); @endphp @for($i = 0; $i < count($current_work_academic_load); $i += 3) @endfor

• {{ trim($current_work_academic_load[$i]) }}

{{ isset($current_work_academic_load[$i+1]) ? '• '.trim($current_work_academic_load[$i+1]) : '' }}

{{ isset($current_work_academic_load[$i+2]) ? '• '.trim($current_work_academic_load[$i+2]) : '' }}

@endif

Current/Ongoing Symptoms and Functional Limitations

@if($data->current_ongoing_symptoms_and_functional_limitations) @php $current_ongoing_symptoms = explode(',',$data->current_ongoing_symptoms_and_functional_limitations); @endphp @for($i = 0; $i < count($current_ongoing_symptoms); $i += 2) @endfor

• {{ trim($current_ongoing_symptoms[$i]) }}

{{ isset($current_ongoing_symptoms[$i+1]) ? '• '.trim($current_ongoing_symptoms[$i+1]) : '' }}

@endif

Notes/other

History of Concussion or Head/Neck Traum

Relevant Medical History (Cardio/Neuro/Metabolic/Respiratory)

Headache/Migraine History Pre-Concussion	{{ $data->headache_migraine_history_pre_concussion == 1 ? 'Yes' : 'No' }} {{ $data->headache_migraine_history_pre_concussion_if_yes }}
Pre-Injury Anxiety/Depression?	{{ $data->pre_injury_anxiety_depression == 1 ? 'Yes' : 'No' }} {{ $data->pre_injury_anxiety_depression_if_yes }}
Hx of Learning Disability?	{{ $data->hx_of_learning_disability == 1 ? 'Yes' : 'No' }} {{ $data->hx_of_learning_disability_if_yes }}
Any Known Vestibular Hx?	{{ $data->any_known_vestibular_hx == 1 ? 'Yes' : 'No' }} {{ $data->any_known_vestibular_hx_if_yes }}
Hx Motion Sickness?	{{ $data->hx_motion_sickness == 1 ? 'Yes' : 'No' }} {{ $data->hx_motion_sickness_if_yes }}
Additional Notes	{{ $data->additional_notes }}

CRANIAL NERVE SCREEN	Clear	Abn.
CN I (olfactory)	cn_i_olfactory == 1 ? 'checked' : '' }}>	cn_i_olfactory == 0 ? 'checked' : '' }}>
CN II (visual fields,pupiIlary reflex)	cn_ii_visual_fields_pupillary_reflex == 1 ? 'checked' : '' }}>	cn_ii_visual_fields_pupillary_reflex == 0 ? 'checked' : '' }}>
CN III(H Pattern)	cn_iii_h_pattern == 1 ? 'checked' : '' }}>	cn_iii_h_pattern == 0 ? 'checked' : '' }}>
CN IV(SO - lat/inf)	cn_iv_so_lat_inf == 1 ? 'checked' : '' }}>	cn_iv_so_lat_inf == 0 ? 'checked' : '' }}>
CN V(Sensory/mastication mm)	cn_v_sensory_mastication_mm == 1 ? 'checked' : '' }}>	cn_v_sensory_mastication_mm == 0 ? 'checked' : '' }}>
CN VI(LR-lat)	cn_vi_lr_lat == 1 ? 'checked' : '' }}>	cn_vi_lr_lat == 0 ? 'checked' : '' }}>
CN VII(facial expression mm)	cn_vii_facial_expression_mm == 1 ? 'checked' : '' }}>	cn_vii_facial_expression_mm == 0 ? 'checked' : '' }}>
CNVIII (nystag, whisper)	cn_viii_nystag_whisper == 1 ? 'checked' : '' }}>	cn_viii_nystag_whisper == 0 ? 'checked' : '' }}>
CN IX(taste/posteriortongue)	cn_ix_taste_posterior_tongue == 1 ? 'checked' : '' }}>	cn_ix_taste_posterior_tongue == 0 ? 'checked' : '' }}>
CN X(uvula, swallow, vocal cords)	cn_x_uvula_swallow_vocal_cords == 1 ? 'checked' : '' }}>	cn_x_uvula_swallow_vocal_cords == 0 ? 'checked' : '' }}>
CN IX(Trap,SCM)	cn_xi_trap_scm == 1 ? 'checked' : '' }}>	cn_xi_trap_scm == 0 ? 'checked' : '' }}>
CN IX(tongue mm, articulation)	cn_xii_tongue_mm_articulation == 1 ? 'checked' : '' }}>	cn_xii_tongue_mm_articulation == 0 ? 'checked' : '' }}>

GROSS NEUROVASCULAR
Cerebellar Signs?	{{ $data->cerebellar_signs == 1 ? 'Yes' : 'No' }}
UMN Signs?	{{ $data->umn_signs == 1 ? 'Yes' : 'No' }}
Sensory Changes?	{{ $data->sensory_changes == 1 ? 'Yes' : 'No' }}
Myotome Weakness?	{{ $data->myotome_weakness == 1 ? 'Yes' : 'No' }}
DTRs	{{ $data->dtrs }}
Vast	{{ $data->vast == 1 ? 'Neg' : 'Pos' }}
5D's, 3N's(list)	{{ $data->{'5ds_3ns_list'} }}

Clin Impression	{{ $data->clin_impression }}
Trajectories	{{ $data->trajectories }}
Referrals	{{ $data->referrals }}
POM	{{ $data->pom }}
Tests to Perform	{{ $data->tests_to_perform }}
Rehab to Initiate	{{ $data->rehab_to_initiate }}
If Others	{{ $data->rehab_to_initiate_if_others }}
Patient Aware Care to be shared w/ Kin and Consents?	{{ $data->patient_aware_care_to_be_shared_w_kin_and_consents == 1 ? 'Yes' : 'No' }}
Name	{{ $data->name }}
Signature	{{ $data->patient_signature }}
Date	{{ $data->patient_date }}

Gaze Fixation	gaze_fixation_1 == 'Normal' ? 'checked' : '' }}> Normal gaze_fixation_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	gaze_fixation_2 == 'Poor Fixation (Sign)' ? 'checked' : '' }}> Poor Fixation (Sign) gaze_fixation_2 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->gaze_fixation_symptoms }}
NPC	npc_1 == 'Normal NPC X3 < 6cm' ? 'checked' : '' }}> Normal NPC X3 < 6cm npc_1 == 'Abnormal / Remote NPC' ? 'checked' : '' }}> Abnormal / Remote NPC npc_1 == 'Abnormal Recovery > 3-4cm' ? 'checked' : '' }}> Abnormal Recovery > 3-4cm	{{ $data->npc_2 }} {{ $data->npc_3 }} {{ $data->npc_4 }} npc_5 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->npc_symptoms }}
Accommodation	accommodation == 'Normal' ? 'checked' : '' }}> Normal accommodation == 'Abnormal Amps (for age)' ? 'checked' : '' }}> Abnormal Amps (for age)	{{ $data->accommodation_notes }}
Pursuits	pursuits_1 == 'Normal' ? 'checked' : '' }}> Normal pursuits_1 == 'Abnormal Horiz' ? 'checked' : '' }}> Abnormal Horiz pursuits_1 == 'Abnormal Vert' ? 'checked' : '' }}> Abnormal Vert	pursuits_2 == 'Nystagmus' ? 'checked' : '' }}> Nystagmus pursuits_2 == 'Saccadic Movement' ? 'checked' : '' }}> Saccadic Movement pursuits_2 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->pursuits_symptoms }}
Saccades	saccades_1 == 'Normal' ? 'checked' : '' }}> Normal saccades_1 == 'Abnormal Horiz' ? 'checked' : '' }}> Abnormal Horiz saccades_1 == 'Abnormal Vert' ? 'checked' : '' }}> Abnormal Vert	saccades_2 == 'Undershoot/Overshoot' ? 'checked' : '' }}> Undershoot/Overshoot saccades_2 == 'Difficult/Slow/Pauses' ? 'checked' : '' }}> Difficult/Slow/Pauses saccades_2 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->saccades_symptoms }}
VOR (180 bpm)	vor_1 == 'Normal' ? 'checked' : '' }}> Normal vor_1 == 'Abnormal Horiz' ? 'checked' : '' }}> Abnormal Horiz vor_1 == 'Abnormal Vert' ? 'checked' : '' }}> Abnormal Vert	vor_2 == 'Does not maintain fixation' ? 'checked' : '' }}> Does not maintain fixation vor_2 == 'Unable to keep target in focus' ? 'checked' : '' }}> Unable to keep target in focus vor_2 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->vor_symptoms }}
VMS (50 bpm)	vms_1 == 'Normal' ? 'checked' : '' }}> Normal vms_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	vms_2 == 'Does not maintain fixation' ? 'checked' : '' }}> Does not maintain fixation vms_2 == 'Symptoms' ? 'checked' : '' }}> Symptoms {{ $data->vms_symptoms }}

Head Thrust Test	special_testing_head_thrust_test == 'Normal' ? 'checked' : '' }}> Normal special_testing_head_thrust_test == 'Abn R' ? 'checked' : '' }}> Abn R special_testing_head_thrust_test == 'Abn L' ? 'checked' : '' }}> Abn L
Dynamic Visual Acuity	special_testing_dynamic_visual_acuity == 'Normal' ? 'checked' : '' }}> Normal special_testing_dynamic_visual_acuity == 'Abnormal (>=2 lines)' ? 'checked' : '' }}> Abnormal (>=2 lines)	{{ $data->special_testing_dynamic_visual_acuity_text }}
Dix Hallpike	special_testing_dix_hallpike == 'Normal' ? 'checked' : '' }}> Normal special_testing_dix_hallpike == 'Abnormal' ? 'checked' : '' }}> Abnormal	{{ $data->special_testing_dix_hallpike_text }}
Lateral Pos/Head Roll	special_testing_lateral_pos_head_roll == 'Normal' ? 'checked' : '' }}> Normal special_testing_lateral_pos_head_roll == 'Abnormal' ? 'checked' : '' }}> Abnormal	{{ $data->special_testing_lateral_pos_head_roll_text }}
Visual Fields (confrontation)	special_testing_visual_fields_confrontation_1 == 'Normal' ? 'checked' : '' }}> Normal special_testing_visual_fields_confrontation_1 == 'Reduced' ? 'checked' : '' }}> Reduced	special_testing_visual_fields_confrontation_2 == 'Generalized' ? 'checked' : '' }}> Generalized special_testing_visual_fields_confrontation_2 == 'Pattern Specific' ? 'checked' : '' }}> Pattern Specific {{ $data->special_testing_visual_fields_confrontation_text }}
Other	special_testing_other == 'Normal' ? 'checked' : '' }}> Normal special_testing_other == 'Abnormal' ? 'checked' : '' }}> Abnormal

Normal Gait	balance_and_gait_normal_gait_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_normal_gait_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_normal_gait_2 == 'Unstable/Abnormal Pattern' ? 'checked' : '' }}> Unstable/Abnormal Pattern balance_and_gait_normal_gait_2 == 'Unilateral Drift R L' ? 'checked' : '' }}> Unilateral Drift R L
Tandem Gait (fwd, bkwd) Eyes open, 5 steps*	balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_2 == 'Fall/Unstable/Overstep' ? 'checked' : '' }}> Fall/Unstable/Overstep balance_and_gait_tandem_gait_fwd_bkwd_eyes_open_5_steps_2 == 'Unilateral Drift R L' ? 'checked' : '' }}> Unilateral Drift R L
Tandem Gait (fwd, bkwd) Eyes closed, 5 steps*	balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_2 == 'Fall/Unstable/Overstep' ? 'checked' : '' }}> Fall/Unstable/Overstep balance_and_gait_tandem_gait_fwd_bkwd_eyes_closed_5_steps_2 == 'Unilateral Drift R L' ? 'checked' : '' }}> Unilateral Drift R L
Balance: Feet together (Firm) Eyes closed (20s)*	balance_and_gait_balance_feet_together_firm_eyes_closed_20s_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_balance_feet_together_firm_eyes_closed_20s_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2 == 'Fall Out of Position' ? 'checked' : '' }}> Fall Out of Position balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2 == 'Sway' ? 'checked' : '' }}>Sway balance_and_gait_balance_feet_together_firm_eyes_closed_20s_2 == 'Symptoms (Dizzy)' ? 'checked' : '' }}>Symptoms (Dizzy)
Balance: Semi Tandem (Firm) Eyes closed (20s)*	balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2 == 'Fall Out of Position' ? 'checked' : '' }}> Fall Out of Position balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2 == 'Sway' ? 'checked' : '' }}>Sway balance_and_gait_balance_semi_tandem_firm_eyes_closed_20s_2 == 'Symptoms (Dizzy)' ? 'checked' : '' }}>Symptoms (Dizzy)
Balance: Feet Together (Foam) Eyes closed (20s)*	balance_and_gait_balance_feet_together_foam_eyes_closed_20s_1 == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_balance_feet_together_foam_eyes_closed_20s_1 == 'Abnormal' ? 'checked' : '' }}> Abnormal	balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2 == 'Fall Out of Position' ? 'checked' : '' }}> Fall Out of Position balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2 == 'Sway' ? 'checked' : '' }}>Sway balance_and_gait_balance_feet_together_foam_eyes_closed_20s_2 == 'Symptoms (Dizzy)' ? 'checked' : '' }}>Symptoms (Dizzy)
Others	balance_and_gait_others == 'Normal' ? 'checked' : '' }}> Normal balance_and_gait_others == 'Abnormal' ? 'checked' : '' }}> Abnormal

Upper Cervical Ligs	cervical_ortho_screen_upper_cervical_ligs == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_upper_cervical_ligs == 'Abnormal' ? 'checked' : '' }}> Abnormal	{{ $data->cervical_ortho_screen_upper_cervical_ligs_text }}
Range Of Motions Flexion(5d) Extension (60d) Right Lateral Flexion (40-45d) Left Lateral Flexion (40-45d) Right Rotation (80d) Left Rotation (80d)	cervical_ortho_screen_flexion_5d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_flexion_5d == 'Reduced' ? 'checked' : '' }}> Reduced cervical_ortho_screen_extension_60d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_extension_60d == 'Reduced' ? 'checked' : '' }}> Reduced cervical_ortho_screen_right_lateral_flexion_40_45d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_right_lateral_flexion_40_45d == 'Reduced' ? 'checked' : '' }}> Reduced cervical_ortho_screen_left_lateral_flexion_40_45d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_left_lateral_flexion_40_45d == 'Reduced' ? 'checked' : '' }}> Reduced cervical_ortho_screen_right_rotation_80d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_right_rotation_80d == 'Reduced' ? 'checked' : '' }}> Reduced cervical_ortho_screen_left_rotation_80d == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_left_rotation_80d == 'Reduced' ? 'checked' : '' }}> Reduced	{{ $data->cervical_ortho_screen_range_of_motion_text }}
Joint Tenderness Upper Cervical (C1-3) Lower Cervical (C4-7)	cervical_ortho_screen_upper_cervical_c1_3 == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_upper_cervical_c1_3 == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction cervical_ortho_screen_lower_cervical_c4_7 == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_lower_cervical_c4_7 == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction	{{ $data->cervical_ortho_screen_joint_tenderness_text }}
Myofascial Tone/Tenderness Suboccipital Other	cervical_ortho_screen_suboccipital == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_suboccipital == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction cervical_ortho_screen_other == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_other == 'Pain/Restriction' ? 'checked' : '' }}> Pain/Restriction	{{ $data->cervical_ortho_screen_myofascial_tone_tenderness_text }}
Special Testing (eg. C-Flex/Rot; Comp/Spurl/DNF/N.Torsion/Rotary stool):	cervical_ortho_screen_special_testing_c_flex_rot == 'Normal' ? 'checked' : '' }}> Normal cervical_ortho_screen_special_testing_c_flex_rot == 'Abnormal' ? 'checked' : '' }}> Abnormal	{{ $data->cervical_ortho_screen_special_testing_c_flex_rot_text }}