@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>Patient Assessment Evaluation Form</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 py-3">
                                        <h4>&nbsp;</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" class="toggle-input" data-target="cerebellar_signs_problem_text" value="1" name="cerebellar_signs">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" class="toggle-input" data-target="cerebellar_signs_problem_text" value="0" name="cerebellar_signs">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12" id="cerebellar_signs_problem_text" style="display:none;">
                                                <input class="form-control pq-bg-white" name="cerebellar_signs_if_yes" type="text" placeholder="If, Yes" value="">
                                            </div>
                                            <div class="col-lg-12 ">
                                                <strong>UMN Signs? </strong>						
                                                <input type="radio" class="toggle-input" data-target="umn_signs_problem_text" value="1" name="umn_signs">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" class="toggle-input" data-target="umn_signs_problem_text" value="0" name="umn_signs">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12" id="umn_signs_problem_text" style="display:none;">
                                                <input class="form-control pq-bg-white" name="umn_signs_if_yes" type="text" placeholder="If, Yes" value="">
                                            </div>
                                            <div class="col-lg-12 ">
                                                <strong>Sensory Changes? </strong>						
                                                <input type="radio" class="toggle-input" data-target="sensory_changes_problem_text" value="1" name="sensory_changes">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" class="toggle-input" data-target="sensory_changes_problem_text" value="0" name="sensory_changes">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12" id="sensory_changes_problem_text" style="display:none;">
                                                <input class="form-control pq-bg-white" name="sensory_changes_if_yes" type="text" placeholder="If, Yes" value="">
                                            </div>
                                            <div class="col-lg-12 ">
                                                <strong>Myotome Weakness? </strong>						
                                                <input type="radio" class="toggle-input" data-target="myotome_weakness_problem_text" value="1" name="myotome_weakness">
                                                &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                                <span class="form-control-option">
                                                    <input type="radio" class="toggle-input" data-target="myotome_weakness_problem_text" value="0" name="myotome_weakness">
                                                    &nbsp;No
                                                </span>
                                            </div> 
                                            <div class="col-lg-12" id="myotome_weakness_problem_text" style="display:none;">
                                                <input class="form-control pq-bg-white" name="myotome_weakness_if_yes" type="text" placeholder="If, Yes" value="">
                                            </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" class="toggle-input" data-target="aware_care_problem_text" value="1" name="patient_aware_care_to_be_shared_w_kin_and_consents">
                                        &nbsp;Yes &nbsp;&nbsp;&nbsp;&nbsp;
                                        <span class="form-control-option">
                                            <input type="radio" class="toggle-input" data-target="aware_care_problem_text" value="0" name="patient_aware_care_to_be_shared_w_kin_and_consents">
                                            &nbsp;No
                                        </span>
                                    </div>
                                    <div class="col-lg-12" id="aware_care_problem_text" style="display:none;">
                                        <input class="form-control pq-bg-white" name="patient_aware_care_to_be_shared_w_kin_and_consents_if_yes" type="text" placeholder="If, Yes" value="">
                                    </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>
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