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<?php /** * Blank form template */ class WeForms_Template_Patient_Intake_Form extends WeForms_Form_Template { public function __construct() { parent::__construct(); $this->enabled = class_exists( 'WeForms_Pro' ); $this->title = __( 'Patient Intake Form', 'weforms' ); $this->description = __( 'This is a Patient Intake Form which gathers Medical History Data and useful information.', 'weforms' ); $this->image = WEFORMS_ASSET_URI . '/images/form-template/patient-intake-form.png'; $this->category = 'registration'; } /** * Get the form fields * * @return array */ public function get_form_fields() { $all_fields = $this->get_available_fields(); $form_fields = [ array_merge( $all_fields['name_field']->get_field_props(), [ 'required' => 'yes', 'format' => 'first-middle-last', 'first_name' => [ 'placeholder' => '', 'default' => '', 'sub' => __( 'First Name', 'weforms' ), ], 'middle_name' => [ 'placeholder' => '', 'default' => '', 'sub' => __( 'Middle Name', 'weforms' ), ], 'last_name' => [ 'placeholder' => '', 'default' => '', 'sub' => __( 'Last Name', 'weforms' ), ], 'hide_subs' => false, 'name' => 'format', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'required' => 'yes', 'label' => __( 'Age', 'weforms' ), 'name' => 'age', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Preferred Name or Nickname', 'weforms' ), 'name' => 'nickname', ] ), array_merge( $all_fields['dropdown_field']->get_field_props(), [ 'label' => __( 'Patient\'s gender', 'weforms' ), 'name' => 'nickname', 'options' => [ 'male' => __( 'Male', 'weforms' ), 'female' => __( 'Female', 'weforms' ), ], 'first' => ' ', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Spouses Name', 'weforms' ), 'name' => 'spause_name', ] ), array_merge( $all_fields['address_field']->get_field_props(), [ 'label' => __( 'Address', 'weforms' ), 'name' => 'address', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'required' => 'yes', 'label' => __( 'SSN', 'weforms' ), 'name' => 'ssn', ] ), array_merge( $all_fields['date_field']->get_field_props(), [ 'required' => 'yes', 'label' => __( 'Patient Birth Date', 'weforms' ), 'name' => 'patient_birth_date', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'Home Phone', 'weforms' ), 'name' => 'hone_phone', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'Work Phone', 'weforms' ), 'name' => 'work_phone', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'Cell Phone', 'weforms' ), 'name' => 'cell_phone', ] ), array_merge( $all_fields['email_address']->get_field_props(), [ 'required' => 'yes', 'label' => __( 'Patient E-Mail', 'weforms' ), 'name' => 'patient_email', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Work Status', 'weforms' ), 'name' => 'work_status', 'options' => [ 'employed' => __( 'Employed', 'weforms' ), 'unemployed' => __( 'Unemployed', 'weforms' ), 'retired' => __( 'Retired', 'weforms' ), 'disabled' => __( 'Disabled fom work', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Employer', 'weforms' ), 'name' => 'employer', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Occupation', 'weforms' ), 'name' => 'occupation', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Marital Status', 'weforms' ), 'name' => 'marital_status', 'options' => [ 'single' => __( 'Single', 'weforms' ), 'married' => __( 'Married', 'weforms' ), 'widowed' => __( 'Widowed', 'weforms' ), 'divorced' => __( 'Divorced', 'weforms' ), 'separated' => __( 'Separated', 'weforms' ), 'domestic_partner' => __( 'Domestic Partner', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Subscriber Name', 'weforms' ), 'name' => 'subscriber_name', ] ), array_merge( $all_fields['date_field']->get_field_props(), [ 'label' => __( 'Subscriber Birth Date', 'weforms' ), 'name' => 'subscriber_birth_date', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Subscriber SSN/ID', 'weforms' ), 'name' => 'subscriber_ssn_id', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'Group Number', 'weforms' ), 'name' => 'group_number', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'Behavioral Health Insurance Carrier (may be different than medical)', 'weforms' ), 'name' => 'group_number', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Subscriber Employer', 'weforms' ), 'name' => 'group_number', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'PCP Name', 'weforms' ), 'name' => 'pcp_name', ] ), array_merge( $all_fields['numeric_text_field']->get_field_props(), [ 'label' => __( 'PCP Phone Number', 'weforms' ), 'name' => 'pcp_phone_Number', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'PCP Fax #', 'weforms' ), 'name' => 'pcp_fax', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you use tobacco in any form?', 'weforms' ), 'name' => 'tobacco', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'If yes, please list type , amount and frequency of use', 'weforms' ), 'name' => 'amount_and_frequency', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you use Alcohol in any form?', 'weforms' ), 'name' => 'use_alcohol', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Do you use Alcohol in any form?', 'weforms' ), 'name' => 'alcohol_friquency', ] ), array_merge( $all_fields['textarea_field']->get_field_props(), [ 'label' => __( 'Are you taking any medication? If yes, please list medication and doage per day', 'weforms' ), 'name' => 'medicin_list', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Abnormal Bleeding', 'weforms' ), 'name' => 'abnormal_bleeding', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Alcohol Abuse', 'weforms' ), 'name' => 'alcohol_abuse', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Allergies', 'weforms' ), 'name' => 'allergies', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Anemia', 'weforms' ), 'name' => 'anemia', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Angina Pectoris', 'weforms' ), 'name' => 'angina_pectoris', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Arthritis', 'weforms' ), 'name' => 'arthritis', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Artificial Heart Valve', 'weforms' ), 'name' => 'heart_valve', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Asthma', 'weforms' ), 'name' => 'asthma', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Blood Transfusion', 'weforms' ), 'name' => 'blood_transfusion', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Cancer', 'weforms' ), 'name' => 'cancer', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Chemotherapy', 'weforms' ), 'name' => 'chemotherapy', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Congenital Heart Defect', 'weforms' ), 'name' => 'congenital_heart_defect', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Diabetes', 'weforms' ), 'name' => 'diabetes', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Difficulty Breathing', 'weforms' ), 'name' => 'difficulty_breathing', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Drug Abuse', 'weforms' ), 'name' => 'drug_abuse', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Emphysema', 'weforms' ), 'name' => 'emphysema', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Epilepsy', 'weforms' ), 'name' => 'epilepsy', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Facial Surgery', 'weforms' ), 'name' => 'facial_surgery', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Fainting Spells', 'weforms' ), 'name' => 'fainting_spells', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Fever Blisters', 'weforms' ), 'name' => 'fever_blisters', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Frequent Headaches', 'weforms' ), 'name' => 'frequent_headaches', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Glaucoma', 'weforms' ), 'name' => 'glaucoma', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'HIV + AIDS', 'weforms' ), 'name' => 'hiv_aids', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Heart Attack', 'weforms' ), 'name' => 'heart_attack', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Heart Murmur', 'weforms' ), 'name' => 'heart_murmur', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Heart Surgery', 'weforms' ), 'name' => 'heart_surgery', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Hemophilia', 'weforms' ), 'name' => 'hemophilia', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Hepatitis A', 'weforms' ), 'name' => 'hepatitis_a', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Hepatitis B', 'weforms' ), 'name' => 'hepatitis_b', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Hepatitis C', 'weforms' ), 'name' => 'hepatitis_c', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'High Blood Pressure', 'weforms' ), 'name' => 'high_blood_pressure', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Joint Replacement', 'weforms' ), 'name' => 'joint_replacement', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Kidney Problems', 'weforms' ), 'name' => 'kidney_problems', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Liver Disease', 'weforms' ), 'name' => 'liver_disease', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Low Blood Pressure', 'weforms' ), 'name' => 'low_blood_pressure', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Mitral Valve Prolaps', 'weforms' ), 'name' => 'mitral_valve_prolaps', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Pace Maker', 'weforms' ), 'name' => 'pace_maker', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Psychiatric Care', 'weforms' ), 'name' => 'psychiatric_care', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Radiation Therapy', 'weforms' ), 'name' => 'radiation_therapy', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Rheumatic Fever', 'weforms' ), 'name' => 'rheumatic_fever', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Seizures', 'weforms' ), 'name' => 'seizures', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Sexually Transmitted Disease', 'weforms' ), 'name' => 'sexually_transmitted_disease', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Shingles', 'weforms' ), 'name' => 'shingles', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Sickle Cell Disease', 'weforms' ), 'name' => 'sickle_cell_disease', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Sinus Problems', 'weforms' ), 'name' => 'sinus_problems', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Stroke', 'weforms' ), 'name' => 'stroke', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Thyroid Problems', 'weforms' ), 'name' => 'thyroid_problems', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Tuberculosis', 'weforms' ), 'name' => 'tuberculosis', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Ulcers', 'weforms' ), 'name' => 'ulcers', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'How may we help you today?', 'weforms' ), 'name' => 'help_today', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Your current dental health is', 'weforms' ), 'name' => 'ulcers', 'options' => [ 'good' => __( 'Good', 'weforms' ), 'fair' => __( 'Fair', 'weforms' ), 'poor' => __( 'Poor', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you require antibiotics before dental treatment?', 'weforms' ), 'name' => 'require_antibiotics', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Are you currently in pain?', 'weforms' ), 'name' => 'currently_pain', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you now or have you had any pain/discomfort in your jaw joint?', 'weforms' ), 'name' => 'discomfort', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Are you aware of clenching or grinding your teeth?', 'weforms' ), 'name' => 'grinding_your_teeth', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Does it hurt when you chew or open wide to take a bite?', 'weforms' ), 'name' => 'hurt_when', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you have any jaw symptoms or headaches upon waking up in the morning?', 'weforms' ), 'name' => 'jaw_symptoms', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you have pain in the face, cheeks, jaw, joints, throat or temples?', 'weforms' ), 'name' => 'face_pain', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you like your smile?', 'weforms' ), 'name' => 'your_smile', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Is there anything you would like to change about your smile?', 'weforms' ), 'name' => 'change_your_smile', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Are you happy with the color of your teeth?', 'weforms' ), 'name' => 'teeth_color', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Have you ever had gum disease?', 'weforms' ), 'name' => 'gum_disease', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do your gums bleed?', 'weforms' ), 'name' => 'gums_bleed', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Have you ever had a deep cleaning or scaling and root planing?', 'weforms' ), 'name' => 'root_planing', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Floss/Week', 'weforms' ), 'name' => 'floss_week', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Brush/Day', 'weforms' ), 'name' => 'brush_day', ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Are your teeth sensitive to heat, cold or anything else?', 'weforms' ), 'name' => 'teeth_sensitive', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you take fluoride supplements?', 'weforms' ), 'name' => 'fluoride_supplements', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Have you ever had a serious/difficult problem with any previous dental work?', 'weforms' ), 'name' => 'previous_dental_work', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Have you ever had any unfavorable dental experiences?', 'weforms' ), 'name' => 'unfavorable', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Are you apprehensive about dental treatment?', 'weforms' ), 'name' => 'dental_apprehensive', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['checkbox_field']->get_field_props(), [ 'label' => __( 'Do you gag easily?', 'weforms' ), 'name' => 'gag_easily', 'options' => [ 'yes' => __( 'Yes', 'weforms' ), 'no' => __( 'No', 'weforms' ), ], ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'When was your last dental cleaning?', 'weforms' ), 'name' => 'dental cleaning', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'When was you last dental visit?', 'weforms' ), 'name' => 'dental_visit', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'How can we accommodate you better during your dental visit?', 'weforms' ), 'name' => 'accommodate_you_better', ] ), array_merge( $all_fields['text_field']->get_field_props(), [ 'label' => __( 'Is there any specific service and/or concern you would like to inquire about?', 'weforms' ), 'name' => 'dental_inquire', ] ), ]; return $form_fields; } }
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