{"id":8411,"date":"2020-08-14T13:32:30","date_gmt":"2020-08-14T17:32:30","guid":{"rendered":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/?page_id=8411"},"modified":"2020-12-07T17:23:49","modified_gmt":"2020-12-07T22:23:49","slug":"ellenor-physician-visit-form","status":"publish","type":"page","link":"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/ellenor-physician-visit-form\/","title":{"rendered":"LSQ &#8211; Ellenor Johnson Physician Visit Form"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-medium-visibility fusion-no-large-visibility\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 10px;margin-top: 15px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 30px;\">\n<div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/pl-dashboard\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-mobile-nav-logo.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/search-customers\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-customers-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/search-team-members\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-team-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/pl-reporting\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-reporting-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<th style=\"text-align: left; padding-left: 10px;\" align=\"center\"><a href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/pl\/my-account\/\"><img class=\"aligncenter size-full wp-image-575\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2019\/10\/robert-brown-icon.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:15px;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#d3d3d3;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-bottom: 0px;margin-top: 0px;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_6 1_6 fusion-one-sixth fusion-column-first narrow-nav fusion-no-small-visibility\" style=\"width:16.666666666667%;width:calc(16.666666666667% - ( ( 0px + 0px ) * 0.16666666666667 ) );margin-right: 0px;margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;border-width: 0 1px 0 0;border-color:#cccccc;border-style:solid;padding: 0px 0px 0px 0px;\"><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:25px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"imageframe-align-center\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\" style=\"width:100%;max-width:34px;\"><a class=\"fusion-no-lightbox\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/community-dashboard\/\" target=\"_self\"><img width=\"38\" height=\"47\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-Icon-Color.png\" class=\"img-responsive wp-image-4378\"\/><\/a><\/span><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:90px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-1\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Admin\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/admin-legacy-at-savannah-quarters\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-account-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-2\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Residents\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-residents\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-residents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-3\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Health\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-health\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-health-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-4\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Documents\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-documents\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-documents-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-5\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Reporting\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-reporting\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-reporting-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-6\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Social\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-social\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/social-calendar-icon.svg\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-7\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Building Operations\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-building-ops\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/building-ops-icon.svg\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-8\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Associates\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-associates\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-associates-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-9\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Corporate\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-corporate\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-corporate-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-10\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Learning\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/lsq-learning\/\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/03\/yiayia-learning-icon-blue.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-text fusion-text-11\"><p style=\"margin-bottom: 0px;\"><a class=\"yiayia-icon-nav\" title=\"Me\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/community\/community-dashboard\/#\"><img class=\"alignleft size-full wp-image-575\" style=\"margin-left: 5px;\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/10\/jdl-icon-blue-border.png\" alt=\"\" width=\"26\" height=\"26\" \/><\/a><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_2_3 2_3 fusion-two-third middle-width\" style=\"width:66.666666666667%;width:calc(66.666666666667% - ( ( 0px + 0px ) * 0.66666666666667 ) );margin-right: 0px;margin-top:0px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 30px 0px 30px;\"><div class=\"fusion-builder-row fusion-builder-row-inner fusion-row\"><div class=\"fusion-layout-column fusion_builder_column_inner fusion-builder-nested-column-0 fusion_builder_column_inner_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-no-small-visibility\" style=\"margin-top:20px;margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-12\"><div>\n<table border=\"0\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px; padding-top: 3px; table-layout: auto;\" align=\"left\"><a  class=\"shiftnav-toggle shiftnav-toggle-health shiftnav-toggle-button\" tabindex=\"0\" data-shiftnav-target=\"health\" ><i class=\"fa fa-bars\"><\/i>  <\/a>\t<\/th>\n<th style=\"text-align: left; padding-left: 0px; padding-right: 15px; padding-top: 8px;\" align=\"center\"><img class=\"aligncenter size-full wp-image-5566\" src=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/wp-content\/uploads\/2020\/04\/ellenor-johnson-circle-white-36.png\" alt=\"\" width=\"36\" height=\"36\" \/><\/th>\n<th align=\"left\">\n<h1 style=\"margin-bottom: 0px; margin-top: 8px; margin-left: 0px; table-layout: auto;\"><a title=\"Dashboard\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/ellenor-health\/\">Ellenor Johnson<\/a><\/h1>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:30px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-13\"><div style=\"margin-bottom: 15px; border-bottom: 1px solid #bbbbbb;\">\n<table border=\"0\" width=\"100%\" cellspacing=\"0px\">\n<tbody>\n<tr>\n<th style=\"text-align: left; padding-left: 0px;\" align=\"left\" width=\"20%\">\n<h3 style=\"padding: 15px 0 6px 0; margin: 0 0 3px 0; font-size: 18px; line-height: 1; font-family: Roboto Slab,Tahoma,sans-serif; font-weight: 300; color: #005174; background-color: transparent;\">Physician Visit<\/h3>\n<\/th>\n<th style=\"text-align: left; padding-left: 0px; margin-top: 20px; margin-bottom: 0px;\" align=\"right\" width=\"41%\"><\/th>\n<th style=\"text-align: left; padding-left: 0px; margin-top: 20px; margin-bottom: 0px;\" align=\"right\" width=\"30%\"><span style=\"margin-top: 10px; text-align: right;\"><div class=\"frm_forms  with_frm_style frm_style_assessment-no-line\" id=\"frm_form_286_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_assessmenthistory\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Assessment Type and Date<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"286\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_286\" id=\"frm_hide_fields_286\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"assessmenthistory\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_286\" name=\"frm_submit_entry_286\" value=\"6731dc43b7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/8411\" \/><input type=\"hidden\" name=\"item_meta[7572]\" id=\"field_5ugww\" value=\"\"  data-invmsg=\"Hidden is invalid\"   \/>\n<div align=\"right\" id=\"frm_field_7571_container\" class=\"frm_form_field form-field  frm_none_container\">\r\n    <label for=\"field_q42mn\" id=\"field_q42mn_label\" class=\"frm_primary_label\">Dropdown\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[7571]\" id=\"field_q42mn\"  data-frmval=\"Assessment Type  |  Date\" data-invmsg=\"Dropdown is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t<option value=\"Assessment Type  |  Date\"  selected=\"selected\" class=\"\">\n\t\t\tAssessment Type  |  Date\t\t<\/option>\n\t\t\t<option value=\"Quarterly Assessment  |  04\/12\/20\"  class=\"\">\n\t\t\tQuarterly Assessment  |  04\/12\/20\t\t<\/option>\n\t\t\t<option value=\"Quarterly Assessment  |  01\/08\/20\"  class=\"\">\n\t\t\tQuarterly Assessment  |  01\/08\/20\t\t<\/option>\n\t\t\t<option value=\"Significant Change  |  10\/22\/19\"  class=\"\">\n\t\t\tSignificant Change  |  10\/22\/19\t\t<\/option>\n\t\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n<\/span><\/th>\n<th style=\"text-align: right; padding-left: 0px;\" align=\"right\" width=\"3%\"><a title=\"Print\" href=\"https:\/\/bluesouthcreative.com\/staging\/yiayia-web-app\/customer\/lsq-ellenor-physician-visit-print\/\" target=\"_blank\" rel=\"noopener noreferrer\"><div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-1 fb-icon-element fontawesome-icon fa-print fas circle-no\" style=\"font-size:18px;margin-top:4px;margin-right:5px;margin-bottom:0px;\"><\/i><\/div><style>i.fb-icon-element.fontawesome-icon.fb-icon-element-1{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-1:hover { color: #005174;}<\/style><\/a><\/th>\n<th style=\"text-align: right; padding-left: 0px;\" align=\"right\" width=\"3%\"><a href=\"#\"><div class=\"fusion-fa-align-right\"><i class=\"fb-icon-element-2 fb-icon-element fontawesome-icon fa-plus fas circle-no\" style=\"font-size:18px;margin-top:10px;margin-right:5px;margin-bottom:6px;\"><\/i><\/div><style>i.fb-icon-element.fontawesome-icon.fb-icon-element-2{ color: #005174;}i.fb-icon-element.fontawesome-icon.fb-icon-element-2:hover { color: #005174;}<\/style><\/a><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div><div class=\"fusion-text fusion-text-14\"><div class=\"frm_forms  with_frm_style frm_style_minimal-info-style\" id=\"frm_form_338_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_physicians-visit\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Physician's Visit<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"338\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_338\" id=\"frm_hide_fields_338\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"physicians-visit\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_338\" name=\"frm_submit_entry_338\" value=\"6731dc43b7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/staging\/yiayia-web-app\/wp-json\/wp\/v2\/pages\/8411\" \/><input type=\"hidden\" name=\"item_meta[9815]\" id=\"field_72bn6e3973806af4c688d16cd\" value=\"\"  data-invmsg=\"Comp Needs Hidden is invalid\"   \/>\n<div id=\"frm_field_9816_container\" class=\"frm_form_field frm_section_heading form-field  frm_hide_section\">\r\n<h3 class=\"frm_pos_none frm_section_spacing\">Physician Visit<\/h3>\r\n\r\n\r\n<div id=\"frm_field_9817_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth frm_first\">\r\n    <label for=\"field_bl1ry04587b9de3dffb02ec2f\" id=\"field_bl1ry04587b9de3dffb02ec2f_label\" class=\"frm_primary_label\">Physician Details\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bl1ry04587b9de3dffb02ec2f\" name=\"item_meta[9817]\" value=\"Dr. Milo Silver\"  data-sectionid=\"9816\" data-frmval=\"Dr. Milo Silver\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9830_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_xdcpm\" id=\"field_xdcpm_label\" class=\"frm_primary_label\">Physician Phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xdcpm\" name=\"item_meta[9830]\" value=\"808.555.2345\"  data-sectionid=\"9816\" data-frmval=\"808.555.2345\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9832_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_scb20\" id=\"field_scb20_label\" class=\"frm_primary_label\">Change in Medications\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_scb20\" name=\"item_meta[9832]\" value=\"Yes\"  data-sectionid=\"9816\" data-frmval=\"Yes\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9831_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_imauv\" id=\"field_imauv_label\" class=\"frm_primary_label\">New Rx Provided\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_imauv\" name=\"item_meta[9831]\" value=\"Yes\"  data-sectionid=\"9816\" data-frmval=\"Yes\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9837_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_o9cm4\" id=\"field_o9cm4_label\" class=\"frm_primary_label\">Next Appointment Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_o9cm4\" name=\"item_meta[9837]\" value=\"11\/05\/20\"  data-sectionid=\"9816\" data-frmval=\"11\/05\/20\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9836_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_i5vdp\" id=\"field_i5vdp_label\" class=\"frm_primary_label\">Next Appointment Time\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_i5vdp\" name=\"item_meta[9836]\" value=\"10:00 am\"  data-sectionid=\"9816\" data-frmval=\"10:00 am\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9829_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth frm_first\">\r\n    <label for=\"field_hdf1f\" id=\"field_hdf1f_label\" class=\"frm_primary_label\">Weight\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_hdf1f\" name=\"item_meta[9829]\" value=\"136 lbs.\"  data-sectionid=\"9816\" data-frmval=\"136 lbs.\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9825_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_zgqrd\" id=\"field_zgqrd_label\" class=\"frm_primary_label\">Temperature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_zgqrd\" name=\"item_meta[9825]\" value=\"99.0 F\"  data-sectionid=\"9816\" data-frmval=\"99.0 F\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9828_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_knp01\" id=\"field_knp01_label\" class=\"frm_primary_label\">Pulse\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_knp01\" name=\"item_meta[9828]\" value=\"65 bpm\"  data-sectionid=\"9816\" data-frmval=\"65 bpm\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9827_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_nn33f\" id=\"field_nn33f_label\" class=\"frm_primary_label\">Respiratory\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nn33f\" name=\"item_meta[9827]\" value=\"35 bpm\"  data-sectionid=\"9816\" data-frmval=\"35 bpm\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9826_container\" class=\"frm_form_field form-field  frm_top_container frm_sixth\">\r\n    <label for=\"field_mwxm2\" id=\"field_mwxm2_label\" class=\"frm_primary_label\">Blood Pressure\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mwxm2\" name=\"item_meta[9826]\" value=\"120 \/ 75\"  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class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_kctdx\" id=\"field_kctdx_label\" class=\"frm_primary_label\">Current Findings\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[9833]\" id=\"field_kctdx\" rows=\"3\"  data-sectionid=\"9816\" data-frmval=\"Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. \" data-invmsg=\"Current Findings is invalid\" aria-invalid=\"false\"  >Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. <\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9834_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_o2hlh\" id=\"field_o2hlh_label\" class=\"frm_primary_label\">Comments\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[9834]\" id=\"field_o2hlh\" rows=\"3\"  data-sectionid=\"9816\" data-frmval=\"Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. \" data-invmsg=\"Comments is invalid\" aria-invalid=\"false\"  >Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. <\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9835_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_czltb\" id=\"field_czltb_label\" class=\"frm_primary_label\">Suggested Follow-up\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[9835]\" id=\"field_czltb\" rows=\"3\"  data-sectionid=\"9816\" data-frmval=\"Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. \" data-invmsg=\"Suggested Follow-up is invalid\" aria-invalid=\"false\"  >Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. <\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9838_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_first\">\r\n    <label for=\"field_1oi0o\" id=\"field_1oi0o_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[9838]\" id=\"field_1oi0o\" rows=\"3\"  data-sectionid=\"9816\" data-invmsg=\"Signature is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9823_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p  style=\"margin-top: 0px; font-size: 1px; padding-top: 0px;\">&nbsp;<\/p>\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  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