758 lines
43 KiB
HTML
758 lines
43 KiB
HTML
<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="utf-8"/>
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<meta content="width=device-width, initial-scale=1.0" name="viewport"/>
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<title>OT Consultation Form (OT-F-1)</title>
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<!-- Bootstrap 5 CSS -->
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<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.0/dist/css/bootstrap.min.css" rel="stylesheet"/>
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<style>
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body {
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font-family: 'Segoe UI', sans-serif;
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background-color: #f8f9fa;
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padding: 30px;
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}
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.form-section {
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background: #fff;
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padding: 20px;
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border-radius: 10px;
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box-shadow: 0 0 10px rgba(0,0,0,0.05);
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}
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h5 {
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color: #2d2d2d;
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}
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.table td, .table th {
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vertical-align: middle;
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}
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.section-label {
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background-color: #9FDC67;
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color: #fff;
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font-weight: 600;
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padding: 4px 12px;
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border-radius: 5px;
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display: inline-block;
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margin-bottom: 8px;
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}
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.striped-table tbody tr:nth-of-type(odd) {
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background-color: #f9f9f9;
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}
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.striped-table thead {
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background-color: #e8f6df;
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}
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.question-box {
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background-color: #f2fdf2;
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border: 1px solid #9FDC67;
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border-radius: 8px;
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padding: 15px;
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margin-bottom: 15px;
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}
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.question-box .form-check {
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margin-right: 15px;
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}
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</style>
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<script>
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function limitCheckboxes(name, max) {
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const checkboxes = document.querySelectorAll(`input[name='${name}']`);
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checkboxes.forEach(cb => {
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cb.addEventListener('change', () => {
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const checked = [...checkboxes].filter(i => i.checked);
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if (checked.length > max) {
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cb.checked = false;
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alert(`You can select a maximum of ${max} options.`);
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}
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});
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});
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}
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document.addEventListener("DOMContentLoaded", () => {
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limitCheckboxes('difficultyAreas[]', 3);
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});
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</script>
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</head>
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<body>
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<div id="formContent">
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<!-- Report Header (Not visible in browser, added to PDF only) -->
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<div id="reportHeader" style="display:none;">
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<div style="font-family: Arial, sans-serif; text-align: center; padding-bottom: 10px;">
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<img src="img/Aqdar-Logo.png" style="max-height: 150px; margin-bottom: 10px;"/>
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<h2 style="margin: 0;">Agdar Center for Developmental and Behavioral Disorders</h2>
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<p style="margin: 0; font-size: 12px;">Riyadh, Saudi Arabia · +966-XXX-XXXXXXX · agdarcenter.com</p>
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<hr style="margin-top: 10px;"/>
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</div>
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</div>
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<!-- Section 1: Patient Information -->
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<div class="form-section border border-success-subtle p-4 mt-3 mb-4 rounded shadow-sm">
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<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">1. Patient Information</h5>
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<div class="row mb-3">
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<div class="col-md-6">
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<label class="form-label" for="patientName">Full Name</label>
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<input class="form-control" id="patientName" name="patientName" placeholder="Enter full name" type="text"/>
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</div>
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<div class="col-md-3">
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<label class="form-label" for="dob">Date of Birth</label>
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<input class="form-control" id="dob" name="dob" type="date"/>
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</div>
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<div class="col-md-3">
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<label class="form-label" for="gender">Gender</label>
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<select class="form-select" id="gender" name="gender">
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<option value="">Select</option>
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<option>Male</option>
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<option>Female</option>
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</select>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<label class="form-label" for="consultationDate">Date of Consultation</label>
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<input class="form-control" id="consultationDate" name="consultationDate" type="date"/>
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</div>
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<div class="col-md-8">
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<label class="form-label" for="therapistName">Therapist Name</label>
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<input class="form-control" id="therapistName" name="therapistName" placeholder="Enter therapist name" type="text"/>
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</div>
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</div>
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</div>
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<!-- SECTION 2 -->
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<div class="form-section pt-4 pb-4 border-bottom mb-4">
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<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">1. Reasons of Referral</h5>
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<div class="mb-3">
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<label class="form-label" for="referralReason">Select the reason for referral <span class="text-danger">*</span></label>
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<select class="form-select" id="referralReason" name="referralReason" required="">
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<option disabled="" selected="" value="">-- Please select --</option>
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<option value="Diagnosis">Multi-disciplinary Team Diagnosis</option>
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<option value="Consultation">Consultation</option>
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<option value="Assessment">Assessment</option>
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<option value="Intervention">Intervention</option>
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<option value="ParentTraining">Parent Training</option>
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</select>
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</div>
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<small class="form-text text-muted">Select only one option that best describes the primary reason for referral to OT.</small>
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</div>
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<!--
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==============================================
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SECTION 3: Areas of Difficulty
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Agdar HIS System | OT Consultation Form (OT-F-1)
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Style: Multi-select checkboxes with text inputs
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Logic: Max 3 selections
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==============================================
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-->
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<div class="form-section pt-4 pb-4 border-bottom mb-4">
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<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">2. Areas of Difficulty (Select up to 3)</h5>
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<p class="mb-2">Please select up to <strong>3 areas</strong> where your child has shown difficulties in the past 3 months, and provide brief details for each selected item:</p>
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<!-- Full list from Word document -->
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<div class="row">
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<div class="col-md-6">
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<div class="form-check mb-3">
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<input class="form-check-input" id="sensory" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="sensory">Sensory skills</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="sensoryDetails"
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name="sensoryDetails"
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placeholder="e.g., hypersensitivity, movement seeking">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="fineMotor" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="fineMotor">Fine motor skills</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="fineMotorDetails"
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name="fineMotorDetails"
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placeholder="e.g., coloring, using scissors">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="grossMotor" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="grossMotor">Gross motor skills</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="grossMotorDetails"
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name="grossMotorDetails"
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placeholder="e.g., running, stairs, ball play">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="oralMotor" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="oralMotor">Oral motor / Feeding</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="oralMotorDetails"
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name="oralMotorDetails"
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placeholder="e.g., chewing, straw drinking">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="adl" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="adl">ADL Activities</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="adlDetails"
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name="adlDetails"
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placeholder="e.g., dressing, toileting">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="handwriting" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="handwriting">Handwriting</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="handwritingDetails"
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name="handwritingDetails"
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placeholder="e.g., forming letters">
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-check mb-3">
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<input class="form-check-input" id="play" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="play">Play</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="playDetails"
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name="playDetails"
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placeholder="e.g., pretend play, object use">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="social" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="social">Social skills</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="socialDetails"
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name="socialDetails"
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placeholder="e.g., turn-taking, sharing">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="selfInjury" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="selfInjury">Self-injurious behavior</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="selfInjuryDetails"
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name="selfInjuryDetails"
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placeholder="e.g., head banging">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="disorganized" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="disorganized">Disorganized behaviors</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="disorganizedDetails"
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name="disorganizedDetails"
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placeholder="e.g., aggression, transitions">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="homeRec" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="homeRec">Home recommendations</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="homeRecDetails"
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name="homeRecDetails"
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placeholder="e.g., sensory equipment">
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</div>
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<div class="form-check mb-3">
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<input class="form-check-input" id="parentEd" name="difficultyAreas[]" type="checkbox">
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<label class="form-check-label" for="parentEd">Parental education</label>
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<input class="form-control form-control-sm mt-1" type="text"
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id="parentEdDetails"
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name="parentEdDetails"
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placeholder="e.g., workshops, strategies">
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</div>
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</div>
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</div>
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<small class="form-text text-muted mt-2">Maximum 3 selections allowed.</small>
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</div>
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<!-- SECTION 4: Developmental History -->
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<div class="form-section pt-4 pb-4 border-bottom mb-4">
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<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">3. Developmental History</h5>
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<p>Please provide approximate ages or observations related to your child’s developmental milestones:</p>
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<table class="table table-bordered table-striped table-sm align-middle">
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<thead class="table-light">
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<tr>
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<th style="width: 60%;">Milestone</th>
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<th>Age / Notes</th>
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</tr>
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</thead>
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<tbody>
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<tr><td>Controlling head</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_headControl" name="milestone_headControl" /></td></tr>
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<tr><td>Reaching for object</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_reachObject" name="milestone_reachObject" /></td></tr>
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<tr><td>Rolling over both ways</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_rollOver" name="milestone_rollOver" /></td></tr>
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<tr><td>Finger feeding</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_fingerFeed" name="milestone_fingerFeed" /></td></tr>
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<tr style="border-left: 4px solid #9FDC67;"><td><strong>Sitting alone</strong> <span class="text-danger">*</span></td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_sitting" name="milestone_sitting" required /></td></tr>
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<tr><td>Pulling to stand</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_pullStand" name="milestone_pullStand" /></td></tr>
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<tr style="border-left: 4px solid #9FDC67;"><td><strong>Creeping on all fours</strong> <span class="text-danger">*</span></td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_crawling" name="milestone_crawling" required /></td></tr>
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<tr><td>Drawing a circle</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_drawCircle" name="milestone_drawCircle" /></td></tr>
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<tr><td>Eating with spoon</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_spoon" name="milestone_spoon" /></td></tr>
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<tr><td>Cutting with scissors</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_cutScissors" name="milestone_cutScissors" /></td></tr>
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<tr style="border-left: 4px solid #9FDC67;"><td><strong>Walking</strong> <span class="text-danger">*</span></td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_walking" name="milestone_walking" required /></td></tr>
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<tr><td>Drinking from a cup</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_drinkCup" name="milestone_drinkCup" /></td></tr>
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<tr><td>Jumping</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_jump" name="milestone_jump" /></td></tr>
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<tr><td>Hopping</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_hop" name="milestone_hop" /></td></tr>
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<tr><td>Hopping on one foot</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_hopOneFoot" name="milestone_hopOneFoot" /></td></tr>
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<tr><td>Riding a bike</td>
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<td><input class="form-control form-control-sm" type="text" id="milestone_bike" name="milestone_bike" /></td></tr>
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</tbody>
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</table>
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<hr class="mt-4 mb-3"/>
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<h6 class="fw-semibold text-muted">Motor Learning & Regression</h6>
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<fieldset class="mb-3">
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<legend class="form-label">Does your child have difficulty learning new motor skills?</legend>
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<div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="motorYes" name="motorLearning" type="radio" value="yes"/>
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<label class="form-check-label" for="motorYes">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="motorNo" name="motorLearning" type="radio" value="no"/>
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<label class="form-check-label" for="motorNo">No</label>
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</div>
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</div>
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<input class="form-control form-control-sm mt-2"
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type="text"
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id="motorLearningDetails"
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name="motorLearningDetails"
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placeholder="If yes, describe the difficulties">
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</fieldset>
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<fieldset class="mb-3">
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<legend class="form-label">Did the child lose any previously gained motor skills?</legend>
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<div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="regression" name="motorLoss" type="radio" value="yes"/>
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<label class="form-check-label" for="regression">Yes</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" id="lossNo" name="motorLoss" type="radio" value="no"/>
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<label class="form-check-label" for="lossNo">No</label>
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</div>
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</div>
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<input class="form-control form-control-sm mt-2"
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type="text"
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id="regressionDetails"
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name="regressionDetails"
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placeholder="If yes, describe the regression">
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</fieldset>
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</div>
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<!-- SECTION 5 -->
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<div class="form-section pt-4 pb-4 border-bottom mb-4">
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<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">4. Self-Help Skills</h5>
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<p>Please indicate whether your child could perform the following tasks during the specified age range.</p>
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<table class="table table-bordered table-sm striped-table">
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<thead class="table-light">
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<tr>
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<th style="width: 15%;">Age Range</th>
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<th style="width: 45%;">Task</th>
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<th class="text-center" style="width: 10%;">Yes</th>
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<th class="text-center" style="width: 10%;">No</th>
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<th style="width: 20%;">Comments</th>
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</tr>
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</thead>
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<tbody>
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<tr><td><span class="section-label">8 – 9 months</span></td><td>Grasps small items with thumb and index finger</td><td class="text-center"><input name="grasp_8_9" type="radio" value="yes"/></td><td class="text-center"><input name="grasp_8_9" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="grasp_8_9_note" name="grasp_8_9_note" /></td></td></tr>
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<tr><td></td><td>Finger feeds self</td><td class="text-center"><input name="fingerfeed_8_9" type="radio" value="yes"/></td><td class="text-center"><input name="fingerfeed_8_9" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="fingerfeed_8_9_note" name="fingerfeed_8_9_note" /></td></td></tr>
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<tr><td><span class="section-label">12 – 18 months</span></td><td>Holds a spoon</td><td class="text-center"><input name="holdspoon_12_18" type="radio" value="yes"/></td><td class="text-center"><input name="holdspoon_12_18" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="holdspoon_12_18_note" name="holdspoon_12_18_note" /></td></td></tr>
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<tr><td></td><td>Removes socks</td><td class="text-center"><input name="removesocks_12_18" type="radio" value="yes"/></td><td class="text-center"><input name="removesocks_12_18" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="removesocks_12_18_note" name="removesocks_12_18_note" /></td></td></tr>
|
||
<tr><td></td><td>Notifies parent that diapers are soiled</td><td class="text-center"><input name="notifydiaper_12_18" type="radio" value="yes"/></td><td class="text-center"><input name="notifydiaper_12_18" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="notifydiaper_12_18_note" name="notifydiaper_12_18_note" /></td></td></tr>
|
||
<tr><td></td><td>Cooperates with dressing</td><td class="text-center"><input name="cooperatedress_12_18" type="radio" value="yes"/></td><td class="text-center"><input name="cooperatedress_12_18" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="cooperatedress_12_18_note" name="cooperatedress_12_18_note" /></td></td></tr>
|
||
<tr><td><span class="section-label">18 – 24 months</span></td><td>Holds and drinks from a cup with minimal spilling</td><td class="text-center"><input name="feedsSelf_18_24" type="radio" value="yes"/></td><td class="text-center"><input name="feedsSelf_18_24" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="feedsSelf_18_24_note" name="feedsSelf_18_24_note" /></td></td></tr>
|
||
<tr><td></td><td>Able to load spoon and bring to mouth with moderate spilling</td><td class="text-center"><input name="usesSpoon_18_24" type="radio" value="yes"/></td><td class="text-center"><input name="usesSpoon_18_24" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="usesSpoon_18_24_note" name="usesSpoon_18_24_note" /></td></td></tr>
|
||
<tr><td><span class="section-label">2 – 3 years</span></td><td>Unzips zippers and unbuttons large buttons</td><td class="text-center"><input name="dresses_2_3" type="radio" value="yes"/></td><td class="text-center"><input name="dresses_2_3" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="dresses_2_3_note" name="dresses_2_3_note" /></td></td></tr>
|
||
<tr><td></td><td>Requires assistance to manage pullover clothing</td><td class="text-center"><input name="removesShoes_2_3" type="radio" value="yes"/></td><td class="text-center"><input name="removesShoes_2_3" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="removesShoes_2_3_note" name="removesShoes_2_3_note" /></td></td></tr>
|
||
<tr><td></td><td>Able to take off pants, coat, socks and shoes without fasteners</td><td class="text-center"><input name="toileting_2_3" type="radio" value="yes"/></td><td class="text-center"><input name="toileting_2_3" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="toileting_2_3_note" name="toileting_2_3_note" /></td></td></tr>
|
||
<tr><td></td><td>Able to feed self with little to no spilling</td><td class="text-center"><input name="feedsInd_2_3" type="radio" value="yes"/></td><td class="text-center"><input name="feedsInd_2_3" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="feedsInd_2_3_note" name="feedsInd_2_3_note" /></td></td></tr>
|
||
<tr><td><span class="section-label">3 – 4 years</span></td><td>Independently dresses self, may need help with fasteners</td><td class="text-center"><input name="dressesSelf_3_4" type="radio" value="yes"/></td><td class="text-center"><input name="dressesSelf_3_4" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="dressesSelf_3_4_note" name="dressesSelf_3_4_note" /></td></td></tr>
|
||
<tr><td></td><td>Independent with toilet control and notification</td><td class="text-center"><input name="independentToileting_3_4" type="radio" value="yes"/></td><td class="text-center"><input name="independentToileting_3_4" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="independentToileting_3_4_note" name="independentToileting_3_4_note" /></td></td></tr>
|
||
<tr><td><span class="section-label">5 – 6 years</span></td><td>Independent with all dressing, including shoe tying</td><td class="text-center"><input name="dressingComplete_5_6" type="radio" value="yes"/></td><td class="text-center"><input name="dressingComplete_5_6" type="radio" value="no"/></td><td><td><input class="form-control form-control-sm" type="text" id="dressingComplete_5_6_note" name="dressingComplete_5_6_note" /></td></td></tr>
|
||
</tbody>
|
||
</table>
|
||
<small class="form-text text-muted">If "No" is selected, please provide a brief explanation in the comment column.</small>
|
||
</div>
|
||
<!-- SECTION 6 -->
|
||
<div class="form-section pt-4 pb-4 border-bottom mb-4">
|
||
<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">5. Eating / Feeding</h5>
|
||
<p>Please respond to the following regarding your child’s eating habits:</p>
|
||
<div class="question-box">
|
||
<fieldset class="mb-3">
|
||
<legend class="form-label fw-semibold">Does your child eat a healthy variety of food?</legend><br/>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="healthyYes" name="varietyHealthy" type="radio" value="yes"/>
|
||
<label class="form-check-label" for="healthyYes">Yes</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="healthyNo" name="varietyHealthy" type="radio" value="no"/>
|
||
<label class="form-check-label" for="healthyNo">No</label>
|
||
</div>
|
||
</fieldset>
|
||
<fieldset class="mb-3">
|
||
<legend class="form-label fw-semibold">Does your child eat a variety of textures and flavors?</legend><br/>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="texturesYes" name="varietyTextures" type="radio" value="yes"/>
|
||
<label class="form-check-label" for="texturesYes">Yes</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="texturesNo" name="varietyTextures" type="radio" value="no"/>
|
||
<label class="form-check-label" for="texturesNo">No</label>
|
||
</div>
|
||
</fieldset>
|
||
<fieldset class="mb-3">
|
||
<legend class="form-label fw-semibold">Does your child easily participate in family meals?</legend><br/>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="mealsYes" name="familyMeals" type="radio" value="yes"/>
|
||
<label class="form-check-label" for="mealsYes">Yes</label>
|
||
</div>
|
||
<div class="form-check form-check-inline">
|
||
<input class="form-check-input" id="mealsNo" name="familyMeals" type="radio" value="no"/>
|
||
<label class="form-check-label" for="mealsNo">No</label>
|
||
</div>
|
||
</fieldset>
|
||
</div>
|
||
<div class="mb-3">
|
||
<label class="form-label fw-semibold" for="eatingComments">Comments, concerns, or questions related to eating:</label>
|
||
<textarea class="form-control" id="eatingComments" name="eatingComments" placeholder="Optional notes..." rows="3"></textarea>
|
||
</div>
|
||
</div>
|
||
<!-- Section 7: Current and Previous Behaviors -->
|
||
<div class="form-section pt-4 pb-4 border-bottom mb-4">
|
||
<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">6. Current and Previous Behaviors</h5>
|
||
<p>Please select Yes / No / Sometimes for each behavior. Add comments where applicable.</p>
|
||
<div class="mb-4">
|
||
<span class="section-label">Infant Behavior (First 12 Months)</span>
|
||
<table class="table table-bordered table-sm striped-table">
|
||
<thead>
|
||
<tr>
|
||
<th>Behavior</th>
|
||
<th class="text-center">Yes</th>
|
||
<th class="text-center">No</th>
|
||
<th class="text-center">Sometimes</th>
|
||
</tr>
|
||
</thead>
|
||
<tbody>
|
||
<tr><td>Cried a lot, fussy, irritable</td><td class="text-center"><input name="infant_cried" type="radio" value="yes"/></td><td class="text-center"><input name="infant_cried" type="radio" value="no"/></td><td class="text-center"><input name="infant_cried" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was good, non-demanding</td><td class="text-center"><input name="infant_good" type="radio" value="yes"/></td><td class="text-center"><input name="infant_good" type="radio" value="no"/></td><td class="text-center"><input name="infant_good" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was alert</td><td class="text-center"><input name="infant_alert" type="radio" value="yes"/></td><td class="text-center"><input name="infant_alert" type="radio" value="no"/></td><td class="text-center"><input name="infant_alert" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was quiet</td><td class="text-center"><input name="infant_quiet" type="radio" value="yes"/></td><td class="text-center"><input name="infant_quiet" type="radio" value="no"/></td><td class="text-center"><input name="infant_quiet" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was passive</td><td class="text-center"><input name="infant_passive" type="radio" value="yes"/></td><td class="text-center"><input name="infant_passive" type="radio" value="no"/></td><td class="text-center"><input name="infant_passive" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was active</td><td class="text-center"><input name="infant_active" type="radio" value="yes"/></td><td class="text-center"><input name="infant_active" type="radio" value="no"/></td><td class="text-center"><input name="infant_active" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Liked being held</td><td class="text-center"><input name="infant_likedHeld" type="radio" value="yes"/></td><td class="text-center"><input name="infant_likedHeld" type="radio" value="no"/></td><td class="text-center"><input name="infant_likedHeld" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Resisted being held</td><td class="text-center"><input name="infant_resistedHeld" type="radio" value="yes"/></td><td class="text-center"><input name="infant_resistedHeld" type="radio" value="no"/></td><td class="text-center"><input name="infant_resistedHeld" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was floppy when held</td><td class="text-center"><input name="infant_floppy" type="radio" value="yes"/></td><td class="text-center"><input name="infant_floppy" type="radio" value="no"/></td><td class="text-center"><input name="infant_floppy" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Was tense when held</td><td class="text-center"><input name="infant_tense" type="radio" value="yes"/></td><td class="text-center"><input name="infant_tense" type="radio" value="no"/></td><td class="text-center"><input name="infant_tense" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Had good sleep patterns</td><td class="text-center"><input name="infant_sleepGood" type="radio" value="yes"/></td><td class="text-center"><input name="infant_sleepGood" type="radio" value="no"/></td><td class="text-center"><input name="infant_sleepGood" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Had irregular sleep patterns</td><td class="text-center"><input name="infant_sleepIrregular" type="radio" value="yes"/></td><td class="text-center"><input name="infant_sleepIrregular" type="radio" value="no"/></td><td class="text-center"><input name="infant_sleepIrregular" type="radio" value="sometimes"/></td></tr>
|
||
</tbody>
|
||
</table>
|
||
<label class="form-label mt-2" for="infantComments">Comments:</label>
|
||
<textarea class="form-control" id="infantComments" name="infantComments" placeholder="Optional details..." rows="2"></textarea>
|
||
</div>
|
||
<div class="mb-4">
|
||
<span class="section-label">Current Behavior</span>
|
||
<table class="table table-bordered table-sm striped-table">
|
||
<thead>
|
||
<tr>
|
||
<th>Behavior</th>
|
||
<th class="text-center">Yes</th>
|
||
<th class="text-center">No</th>
|
||
<th class="text-center">Sometimes</th>
|
||
</tr>
|
||
</thead>
|
||
<tbody>
|
||
<tr><td>Is mostly quiet</td><td class="text-center"><input name="current_quiet" type="radio" value="yes"/></td><td class="text-center"><input name="current_quiet" type="radio" value="no"/></td><td class="text-center"><input name="current_quiet" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is overly active</td><td class="text-center"><input name="current_active" type="radio" value="yes"/></td><td class="text-center"><input name="current_active" type="radio" value="no"/></td><td class="text-center"><input name="current_active" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Tires easily</td><td class="text-center"><input name="current_tires" type="radio" value="yes"/></td><td class="text-center"><input name="current_tires" type="radio" value="no"/></td><td class="text-center"><input name="current_tires" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Talks constantly</td><td class="text-center"><input name="current_talks" type="radio" value="yes"/></td><td class="text-center"><input name="current_talks" type="radio" value="no"/></td><td class="text-center"><input name="current_talks" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is impulsive</td><td class="text-center"><input name="current_impulsive" type="radio" value="yes"/></td><td class="text-center"><input name="current_impulsive" type="radio" value="no"/></td><td class="text-center"><input name="current_impulsive" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is restless</td><td class="text-center"><input name="current_restless" type="radio" value="yes"/></td><td class="text-center"><input name="current_restless" type="radio" value="no"/></td><td class="text-center"><input name="current_restless" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is stubborn</td><td class="text-center"><input name="current_stubborn" type="radio" value="yes"/></td><td class="text-center"><input name="current_stubborn" type="radio" value="no"/></td><td class="text-center"><input name="current_stubborn" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is resistant to change</td><td class="text-center"><input name="current_resistant" type="radio" value="yes"/></td><td class="text-center"><input name="current_resistant" type="radio" value="no"/></td><td class="text-center"><input name="current_resistant" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Fights frequently</td><td class="text-center"><input name="current_fights" type="radio" value="yes"/></td><td class="text-center"><input name="current_fights" type="radio" value="no"/></td><td class="text-center"><input name="current_fights" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Exhibits frequent temper tantrums</td><td class="text-center"><input name="current_tantrums" type="radio" value="yes"/></td><td class="text-center"><input name="current_tantrums" type="radio" value="no"/></td><td class="text-center"><input name="current_tantrums" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is clumsy</td><td class="text-center"><input name="current_clumsy" type="radio" value="yes"/></td><td class="text-center"><input name="current_clumsy" type="radio" value="no"/></td><td class="text-center"><input name="current_clumsy" type="radio" value="sometimes"/></td></tr>
|
||
<tr><td>Is frustrated easily</td><td class="text-center"><input name="current_frustrated" type="radio" value="yes"/></td><td class="text-center"><input name="current_frustrated" type="radio" value="no"/></td><td class="text-center"><input name="current_frustrated" type="radio" value="sometimes"/></td></tr>
|
||
</tbody>
|
||
</table>
|
||
<label class="form-label mt-2" for="currentComments">Comments:</label>
|
||
<textarea class="form-control" id="currentComments" name="currentComments" placeholder="Optional details..." rows="2"></textarea>
|
||
</div>
|
||
</div>
|
||
<!-- Section 8: Recommendation -->
|
||
<div class="form-section pt-4 pb-4 border-bottom mb-4">
|
||
<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">7. Recommendation</h5>
|
||
<p>Please provide your professional recommendation based on the consultation findings:</p>
|
||
<div class="mb-3">
|
||
<label class="form-label fw-semibold" for="recommendation">Recommendation</label>
|
||
<textarea class="form-control border-success border-2" id="recommendation" name="recommendation" placeholder="Write your recommendation here..." required="" rows="5"></textarea>
|
||
</div>
|
||
<div class="row">
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-semibold" for="therapistName">Therapist Name</label>
|
||
<input class="form-control" id="therapistName_1" name="therapistName_1" placeholder="Therapist full name" required="" type="text"/>
|
||
</div>
|
||
<div class="col-md-6 mb-3">
|
||
<label class="form-label fw-semibold" for="consultationDate">Date</label>
|
||
<input class="form-control" id="consultationDate_1" name="consultationDate" required="" type="date"/>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<!-- Section 9: Action Buttons -->
|
||
<div class="form-section text-center border border-success-subtle p-4 mt-3 mb-4 rounded shadow-sm no-print">
|
||
<h6 class="fw-bold mb-3 text-success">Actions</h6>
|
||
<button class="btn btn-outline-secondary me-2" onclick="saveDraft()" type="button">💾 Save Draft</button>
|
||
<button class="btn btn-success me-2" onclick="exportToPDF()" type="button">📄 Export to PDF</button>
|
||
<button class="btn btn-primary" onclick="calculateScore()" type="button">📊 Calculate Score & Recommendation</button>
|
||
</div>
|
||
<!-- Section 10: Smart Results Output -->
|
||
<div class="form-section mt-4 border border-success-subtle p-4 rounded shadow-sm" id="resultsSection" style="display:none;">
|
||
<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">9. Smart Results</h5>
|
||
<div class="mb-3" id="scoreSummary"></div>
|
||
<canvas height="200" id="resultsChart"></canvas>
|
||
<div class="mt-4">
|
||
<label class="form-label fw-bold" for="scoreSummaryText">Plain Text Scoring Summary</label>
|
||
<textarea class="form-control" id="scoreSummaryText" name="scoreSummaryText" readonly="" rows="6"></textarea>
|
||
</div>
|
||
<div class="text-end mt-3 no-print">
|
||
<button class="btn btn-outline-success" onclick="downloadSmartResultsPDF()">⬇️ Download Smart Results as PDF</button>
|
||
</div>
|
||
</div>
|
||
</div> <!-- end of #formContent -->
|
||
<style>
|
||
.no-print {
|
||
display: block;
|
||
}
|
||
@media print {
|
||
.no-print {
|
||
display: none !important;
|
||
}
|
||
}
|
||
</style>
|
||
<script src="https://cdnjs.cloudflare.com/ajax/libs/html2canvas/1.4.1/html2canvas.min.js"></script>
|
||
<script>
|
||
document.addEventListener('DOMContentLoaded', function () {
|
||
const today = new Date().toISOString().split('T')[0];
|
||
const consultationDate = document.getElementById('consultationDate');
|
||
if (consultationDate) consultationDate.value = today;
|
||
|
||
const therapistName = localStorage.getItem('agdarTherapistName') || 'Moneer Zakaria';
|
||
const therapistInput = document.getElementById('therapistName');
|
||
if (therapistInput && !therapistInput.value) therapistInput.value = therapistName;
|
||
});
|
||
</script>
|
||
<script src="https://cdnjs.cloudflare.com/ajax/libs/html2pdf.js/0.10.1/html2pdf.bundle.min.js"></script>
|
||
<script>
|
||
function exportToPDF() {
|
||
const original = document.getElementById("formContent");
|
||
const element = original.cloneNode(true);
|
||
|
||
// Reveal existing report header inside the cloned form
|
||
const header = element.querySelector("#reportHeader");
|
||
if (header) header.style.display = "block";
|
||
|
||
// Remove no-print elements
|
||
element.querySelectorAll(".no-print").forEach(e => e.remove());
|
||
|
||
const opt = {
|
||
margin: 0.5,
|
||
filename: 'OT_Consultation_Form.pdf',
|
||
image: { type: 'jpeg', quality: 0.98 },
|
||
html2canvas: { scale: 2, useCORS: true, logging: false },
|
||
jsPDF: { unit: 'in', format: 'a4', orientation: 'portrait' }
|
||
};
|
||
|
||
html2pdf().set(opt).from(element).save();
|
||
}
|
||
</script>
|
||
<script>
|
||
window.jspdf = window.jspdf || {};
|
||
window.jspdf.jsPDF = window.jspdf.jsPDF || window.jspdf.jspdf?.jsPDF;
|
||
</script>
|
||
<!-- Section 11: Clinician Signature -->
|
||
<div class="form-section border border-success-subtle p-4 mt-3 mb-4 rounded shadow-sm">
|
||
<h5 class="fw-bold mb-3" style="border-left: 6px solid #9FDC67; padding-left: 10px;">10. Clinician Signature</h5>
|
||
<div class="row">
|
||
<div class="col-md-6">
|
||
<label class="form-label" for="clinicianName">Clinician Full Name</label>
|
||
<input class="form-control" id="clinicianName" name="clinicianName" placeholder="Enter full name" type="text"/>
|
||
</div>
|
||
<div class="col-md-6">
|
||
<label class="form-label" for="clinicianSignature">Digital Signature (type or draw)</label>
|
||
<input class="form-control" id="clinicianSignature" name="clinicianSignature" placeholder="Type full name as signature" type="text"/>
|
||
</div>
|
||
</div>
|
||
</div>
|
||
<!-- Section 12: Scoring Logic & Auto-Recommendation -->
|
||
<script src="https://cdn.jsdelivr.net/npm/chart.js"></script>
|
||
<script>
|
||
let resultsChart;
|
||
|
||
function calculateScore() {
|
||
document.querySelector("button[onclick='calculateScore()']").disabled = true;
|
||
|
||
let sections = {
|
||
selfHelp: 0,
|
||
behavior: 0,
|
||
developmental: 0,
|
||
eating: 0
|
||
};
|
||
|
||
const selfHelpNames = [
|
||
'grasp_8_9', 'fingerfeed_8_9',
|
||
'holdspoon_12_18', 'removesocks_12_18', 'notifydiaper_12_18', 'cooperatedress_12_18',
|
||
'feedsSelf_18_24', 'usesSpoon_18_24',
|
||
'dresses_2_3', 'removesShoes_2_3', 'toileting_2_3', 'feedsInd_2_3',
|
||
'dressesSelf_3_4', 'independentToileting_3_4',
|
||
'dressingComplete_5_6'
|
||
];
|
||
selfHelpNames.forEach(name => {
|
||
const selected = document.querySelector(`input[name='${name}']:checked`);
|
||
if (selected) sections.selfHelp += selected.value === 'yes' ? 2 : selected.value === 'sometimes' ? 1 : 0;
|
||
});
|
||
|
||
const behaviorNames = [
|
||
'infant_cried', 'infant_good', 'infant_alert', 'infant_quiet', 'infant_passive', 'infant_active',
|
||
'infant_likedHeld', 'infant_resistedHeld', 'infant_floppy', 'infant_tense', 'infant_sleepGood', 'infant_sleepIrregular',
|
||
'current_quiet', 'current_active', 'current_tires', 'current_talks', 'current_impulsive', 'current_restless',
|
||
'current_stubborn', 'current_resistant', 'current_fights', 'current_tantrums', 'current_clumsy', 'current_frustrated'
|
||
];
|
||
behaviorNames.forEach(name => {
|
||
const selected = document.querySelector(`input[name='${name}']:checked`);
|
||
if (selected) sections.behavior += selected.value === 'yes' ? 2 : selected.value === 'sometimes' ? 1 : 0;
|
||
});
|
||
|
||
const milestoneIds = ['milestone_sitting', 'milestone_crawling', 'milestone_walking'];
|
||
milestoneIds.forEach(id => {
|
||
const input = document.getElementById(id);
|
||
if (input && input.value.trim() !== '') sections.developmental += 2;
|
||
});
|
||
|
||
const eatingNames = ['varietyHealthy', 'varietyTextures', 'familyMeals'];
|
||
eatingNames.forEach(name => {
|
||
const selected = document.querySelector(`input[name='${name}']:checked`);
|
||
if (selected) sections.eating += selected.value === 'yes' ? 2 : selected.value === 'sometimes' ? 1 : 0;
|
||
});
|
||
|
||
const criticalFlags = [];
|
||
const flagChecks = [
|
||
{ id: 'regression', label: 'Developmental regression reported' },
|
||
{ id: 'infant_sleepIrregular', label: 'Irregular sleep patterns (infancy)' },
|
||
{ id: 'varietyTextures', label: 'Feeding difficulty with textures' },
|
||
{ id: 'current_fights', label: 'Frequent aggressive behavior (fights)' },
|
||
{ id: 'current_tantrums', label: 'Frequent temper tantrums' },
|
||
{ id: 'current_restless', label: 'High restlessness and inattention' },
|
||
{ id: 'current_resistant', label: 'Strong resistance to change or routines' }
|
||
];
|
||
flagChecks.forEach(flag => {
|
||
const selected = document.querySelector(`input[name='${flag.id}']:checked`);
|
||
if (selected && selected.value === 'yes') criticalFlags.push(flag.label);
|
||
});
|
||
|
||
const totalScore = sections.selfHelp + sections.behavior + sections.developmental + sections.eating;
|
||
let level = "";
|
||
let recommendationText = "";
|
||
|
||
if (totalScore <= 30) {
|
||
level = "⚠️ Needs Immediate Attention";
|
||
recommendationText = "The child presents significant delays or difficulties across multiple developmental domains. Immediate referral to Occupational Therapy and interdisciplinary evaluation is recommended.";
|
||
} else if (totalScore <= 60) {
|
||
level = "⚠ Moderate Difficulty - Follow-Up Needed";
|
||
recommendationText = "The child shows moderate concerns that warrant intervention. Recommend starting OT sessions and monitoring progress within 2–4 months.";
|
||
} else {
|
||
level = "✅ Age-Appropriate Skills";
|
||
recommendationText = "Child demonstrates age-appropriate functioning in assessed areas. Recommend regular developmental screening as part of preventive care.";
|
||
}
|
||
|
||
if (criticalFlags.length > 0) {
|
||
recommendationText += "\n\n⚠ Additional concerns flagged: " + criticalFlags.join('; ') + ". These should be reviewed in the full evaluation.";
|
||
}
|
||
|
||
let flagsHTML = "";
|
||
if (criticalFlags.length > 0) {
|
||
flagsHTML += `<div class='alert alert-danger'><strong>⚠ Critical Concerns:</strong><ul>`;
|
||
criticalFlags.forEach(f => { flagsHTML += `<li>${f}</li>`; });
|
||
flagsHTML += `</ul></div>`;
|
||
}
|
||
|
||
document.getElementById('resultsSection').style.display = 'block';
|
||
document.getElementById('scoreSummary').innerHTML = `
|
||
${flagsHTML}
|
||
<p><strong>Self-Help Score:</strong> ${sections.selfHelp} / 24</p>
|
||
<p><strong>Behavior Score:</strong> ${sections.behavior} / 48</p>
|
||
<p><strong>Developmental History Score:</strong> ${sections.developmental} / 6</p>
|
||
<p><strong>Eating / Feeding Score:</strong> ${sections.eating} / 6</p>
|
||
<p><strong>Total Score:</strong> ${totalScore}</p>
|
||
<p><strong>Interpretation:</strong> ${level}</p>
|
||
`;
|
||
|
||
document.getElementById('recommendation').value = recommendationText;
|
||
const scoreSummaryText = `
|
||
Self-Help Score: ${sections.selfHelp} / 24
|
||
Behavior Score: ${sections.behavior} / 48
|
||
Developmental History Score: ${sections.developmental} / 6
|
||
Eating / Feeding Score: ${sections.eating} / 6
|
||
Total Score: ${totalScore}
|
||
Interpretation: ${level}`.trim();
|
||
|
||
const textBox = document.getElementById('scoreSummaryText');
|
||
if (textBox) textBox.value = scoreSummaryText;
|
||
|
||
|
||
const ctx = document.getElementById('resultsChart').getContext('2d');
|
||
if (resultsChart) resultsChart.destroy();
|
||
resultsChart = new Chart(ctx, {
|
||
type: 'bar',
|
||
data: {
|
||
labels: ['Self-Help', 'Behavior', 'Developmental', 'Eating'],
|
||
datasets: [{
|
||
label: 'Score',
|
||
data: [sections.selfHelp, sections.behavior, sections.developmental, sections.eating],
|
||
backgroundColor: ['#9FDC67', '#9FDC67', '#9FDC67', '#9FDC67'],
|
||
borderWidth: 1
|
||
}]
|
||
},
|
||
options: {
|
||
scales: {
|
||
y: {
|
||
beginAtZero: true,
|
||
title: { display: true, text: 'Score' },
|
||
max: 50
|
||
},
|
||
x: {
|
||
title: { display: true, text: 'Category' }
|
||
}
|
||
},
|
||
plugins: {
|
||
legend: { display: false },
|
||
tooltip: { enabled: true }
|
||
}
|
||
}
|
||
});
|
||
|
||
document.querySelector("button[onclick='calculateScore()']").disabled = false;
|
||
}
|
||
</script>
|
||
</body>
|
||
<!-- end of #formContent -->
|
||
</html>
|