Medical Questionnaire

Please answer the following questions to help our doctors provide the best care

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Current Medications

Please list ALL medications you are currently taking (for any condition)

@if(isset($medicalQuestions['medications']) && count($medicalQuestions['medications']) > 0) @foreach($medicalQuestions['medications'] as $index => $medication)

Medication Name

Dosage

Frequency

@endforeach @else

Medication Name

Dosage

Frequency

@endif

Allergies

Please list any allergies you have

@if(isset($medicalQuestions['allergies']) && count($medicalQuestions['allergies']) > 0) @foreach($medicalQuestions['allergies'] as $index => $allergy)

Allergen

Reaction

@endforeach @else

Allergen

Reaction

@endif

Medical Questionnaire

Please answer these questions to help our doctors provide the best care

How long have you been experiencing symptoms?

Have you been previously diagnosed with this condition (or a related one)?

Yes No Not sure

How would you describe your current symptoms?

Rate your pain or discomfort level (if applicable):

Are you currently taking any medications or treatments SPECIFICALLY for this condition?

Yes No

If yes, list the condition-specific medication names, dosages, and how often you take them. (No need to repeat medications already listed above)

Have you taken any other medications or treatments for this condition in the past?

Yes No

If yes, list any that were helpful or caused side effects.

Are you considering stopping or switching any current medications or treatments?

Yes No

If yes, explain why (e.g., not working, side effects, cost).

Have you had any tests, imaging, or labs related to this condition?

@php $testOptions = ['None', 'Blood tests', 'Urinalysis', 'X-rays', 'CT scan', 'MRI', 'Ultrasound', 'Skin test / Patch test', 'ECG / EKG', 'Other']; $selectedTests = isset($medicalQuestions['tests_imaging']) && is_array($medicalQuestions['tests_imaging']) ? $medicalQuestions['tests_imaging'] : []; @endphp @foreach($testOptions as $option) {{ $option }} @endforeach

Have you had any recent changes in your health, lifestyle, or environment?

Is this condition affecting your ability to work, study, or carry out daily activities?

Yes No

If yes, please describe how it's impacting your life.

Do you have a history of mental health conditions or substance use?

Yes No Prefer not to say

If yes, include diagnosis, medications, or relevant treatments.

Do you have a preferred pharmacy (in case a prescription is needed)?

Is there anything specific you are hoping to accomplish with today's visit?

Treatment-Specific Questions

Please answer the following questions about your treatment

@if($treatment->questions && $treatment->questions->count() > 0) @foreach($treatment->questions as $question) @if(in_array($question->section, $relevantSections) && $question->section !== 'general')

{{ $question->question_text }} @if($question->question_type === 'text') is_required ? 'required' : '' }}> @elseif($question->question_type === 'select') @elseif($question->question_type === 'radio')

@foreach($question->options as $option) question_text)]) && $medicalQuestions[Str::snake($question->question_text)] === $option ? 'checked' : '' }} {{ $question->is_required ? 'required' : '' }} class="form-radio h-4 w-4 text-indigo-600 focus:ring-indigo-500"> {{ $option }} @endforeach

@elseif($question->question_type === 'checkbox')

@foreach($question->options as $option) question_text)]) && is_array($medicalQuestions[Str::snake($question->question_text)]) && in_array($option, $medicalQuestions[Str::snake($question->question_text)]) ? 'checked' : '' }} class="form-checkbox h-4 w-4 text-indigo-600 focus:ring-indigo-500"> {{ $option }} @endforeach

@endif

@endif @endforeach @else

No specific questions for this treatment. Please provide any additional information in the notes section below.

@endif @if(isset($conditionQuestions) && $conditionQuestions->count() > 0)

Condition-Specific Questions

Please answer these additional questions about your specific condition

@foreach($conditionQuestions as $question)

{{ $question->question_text }} @if($question->question_type === 'text') is_required ? 'required' : '' }}> @elseif($question->question_type === 'select') @elseif($question->question_type === 'radio')

@foreach($question->options as $option) condition_id.'_'.Str::snake($question->question_text)]) && $medicalQuestions['condition_'.$question->condition_id.'_'.Str::snake($question->question_text)] === $option ? 'checked' : '' }} {{ $question->is_required ? 'required' : '' }} class="form-radio h-4 w-4 text-indigo-600 focus:ring-indigo-500"> {{ $option }} @endforeach

@elseif($question->question_type === 'checkbox')

@foreach($question->options as $option) condition_id.'_'.Str::snake($question->question_text)]) && is_array($medicalQuestions['condition_'.$question->condition_id.'_'.Str::snake($question->question_text)]) && in_array($option, $medicalQuestions['condition_'.$question->condition_id.'_'.Str::snake($question->question_text)]) ? 'checked' : '' }} class="form-checkbox h-4 w-4 text-indigo-600 focus:ring-indigo-500"> {{ $option }} @endforeach

@endif

@endforeach @endif

Additional Notes