Health Questionnaire PDF Form

Patient Name	{{ $data->patient_name }}
Date	{{ $data->date }}
Family Doctor's Name	{{ $data->doctor_name }}
Doctor's Phone No	{{ $data->doctor_phone }}
1. Do you have any heart problems?	{{ $data->has_heart_problems == 1 ? 'Yes' : 'No' }}
Heart problems?	{{ $data->heart_problems }}
Heart problems files?	{{ $data->heart_problems_file }}
2. Do you have any thyroid problems?	{{ $data->has_thyroid_problems == 1 ? 'Yes' : 'No' }}
Thyroid problems?	{{ $data->thyroid_problems }}
3. Do you have HIGH or LOW blood pressure?	{{ $data->has_blood_pressure == 1 ? 'Yes' : 'No' }}
HIGH or LOW blood pressure?	{{ $data->high_or_low_blood_pressure }}
4. Are you currently taking any medications?	{{ $data->taking_medications == 1 ? 'Yes' : 'No' }}
Medication List	{{ $data->medication_list }}
Medication Image	{{ $data->medication_image }}
5. Have you been diagnosed with arthritis?	{{ $data->has_arthritis == 1 ? 'Yes' : 'No' }}
Diagnosed with arthritis?	{{ $data->diagnosed_with_arthritis }}
6. Do you have diabetes?	{{ $data->has_diabetes == 1 ? 'Yes' : 'No' }}
Diabetes?	{{ $data->diabetes }}
7. Do you have or ever had cancer?	{{ $data->cancer == 1 ? 'Yes' : 'No' }}
Ever had cancer?	{{ $data->ever_had_cancer }}
8. Have you ever broken a bone?	{{ $data->has_broken_bone == 1 ? 'Yes' : 'No' }}
Ever broken a bone?	{{ $data->broken_a_bone }}
9. Do you have any metal fixations, plates, screws, etc.?	{{ $data->has_metal_fixations == 1 ? 'Yes' : 'No' }}
Any metal fixations, plates, screws, etc.?	{{ $data->metal_fixations }}
10. Do you smoke?	{{ $data->do_you_smoke == 1 ? 'Yes' : 'No' }}
How much?	{{ $data->smoke_much }}
11. Do you have any abdominal problems, ie hernia, ulcer?	{{ $data->has_abdominal_problems == 1 ? 'Yes' : 'No' }}
Any abdominal problems, ie hernia, ulcer?	{{ $data->abdominal_problems }}
12. Have you had any previous surgeries?	{{ $data->has_previous_surgeries == 1 ? 'Yes' : 'No' }}
Previous Surgeries List	{{ $data->previous_surgeries_list }}
13. If female, are you pregnant?	{{ $data->is_pregnant == 1 ? 'Yes' : 'No' }}
Could you be pregnant?	{{ $data->pregnant }}
14. Previous car accident?	{{ $data->has_car_accident == 1 ? 'Yes' : 'No' }}
Accident Date	{{ $data->car_accident_date }}
15. Any allergies or skin irritations?	{{ $data->has_allergies == 1 ? 'Yes' : 'No' }}
Any allergies, skin irritations, infections, etc?	{{ $data->any_allergies }}
16. Asthma or respiratory problems?	{{ $data->asthma == 1 ? 'Yes' : 'No' }}
Asthma or any respiratory problems?	{{ $data->asthma }}
17. Any other health problems?	{{ $data->has_other_health_problems == 1 ? 'Yes' : 'No' }}
Any other health problems not listed above?	{{ $data->other_health_problems }}
18. Any reason to avoid physical activity?	{{ $data->has_other_reason == 1 ? 'Yes' : 'No' }}
Any other reason that you should not do physical activities?	{{ $data->any_other_reason }}
Last Physiotherapy Visit	{{ $data->last_physiotherapy_visit }}
Last Physiotherapy Location	{{ $data->last_physiotherapy_location }}
Emergency Contact Person	{{ $data->emergency_contact_person }}
Emergency Phone	{{ $data->emergency_phone }}
Client Signature	{{ $data->client_signature }}