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doc16666 newGeneral4H_medicalauthorizationpacket.pdf
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Page 1
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1 · FIGURE
2 · HEADER
3 · TITLE
4 · HEADING
5 · LIST
6
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9 · TEXT
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11 · TEXT
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13 · HEADING
14 · HEADING
15 · TEXT
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20 · LIST
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31 · HEADING
32 · HEADING
33 · LIST
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47 · TEXT
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Page 2
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1 · FIGURE
2 · HEADER
3 · TEXT
4
5 · HEADING
6 · LIST
7
8
9
10
11
12
13
14
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16
17 · HEADING
18 · FIGURE
19 · TEXT
20 · FIGURE
21 · TEXT
22 · FIGURE
23 · FOOTER
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Page 3
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"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.6.12",
"text_offset": 6,
"text_span": 0
}
}
]
},
{
"id": "p3.6.13",
"order": 42,
"type": "list_item",
"bbox": {
"l": 38.4,
"t": 295.2,
"r": 171.84,
"b": 281.76
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"text": "Skin problems? □ Yes □ No",
"children": [
{
"id": "p3.6.13.1",
"order": 43,
"type": "form_field",
"bbox": {
"l": 117.371532,
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"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
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"text_offset": 15,
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},
{
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"order": 44,
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"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.6.13",
"text_offset": 21,
"text_span": 1
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]
},
{
"id": "p3.6.14",
"order": 45,
"type": "list_item",
"bbox": {
"l": 38.88,
"t": 274.8,
"r": 159.36,
"b": 261.36
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"text": "Head injury? □ Yes □ No",
"children": [
{
"id": "p3.6.14.1",
"order": 46,
"type": "form_field",
"bbox": {
"l": 104.826611,
"t": 273.845064,
"r": 112.02661,
"b": 261.845065
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"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
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},
{
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"order": 47,
"type": "form_field",
"bbox": {
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"r": 140.302796,
"b": 261.845065
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"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.6.14",
"text_offset": 19,
"text_span": 1
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]
},
{
"id": "p3.7",
"order": 48,
"type": "text",
"bbox": {
"l": 328.08,
"t": 539.52,
"r": 544.32,
"b": 525.36
},
"text": "Breathing issues during activity? □ Yes □ No",
"children": [
{
"id": "p3.7.1",
"order": 49,
"type": "form_field",
"bbox": {
"l": 489.936809,
"t": 538.663931,
"r": 497.136809,
"b": 526.663931
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.7",
"text_offset": 34,
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},
{
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"order": 50,
"type": "form_field",
"bbox": {
"l": 518.212993,
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"r": 525.412993,
"b": 526.663931
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.7",
"text_offset": 40,
"text_span": 1
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]
},
{
"id": "p3.8",
"order": 51,
"type": "text",
"bbox": {
"l": 328.56,
"t": 518.4,
"r": 522.24,
"b": 504.48
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"text": "Use of medical equipment? □ Yes □ No",
"children": [
{
"id": "p3.8.1",
"order": 52,
"type": "form_field",
"bbox": {
"l": 466.780556,
"t": 517.6639319999999,
"r": 473.980556,
"b": 505.663932
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.8",
"text_offset": 26,
"text_span": 1
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},
{
"id": "p3.8.2",
"order": 53,
"type": "form_field",
"bbox": {
"l": 495.056744,
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"r": 502.256744,
"b": 505.663932
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"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.8",
"text_offset": 32,
"text_span": 1
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]
},
{
"id": "p3.9",
"order": 54,
"type": "text",
"bbox": {
"l": 328.8,
"t": 497.52,
"r": 472.08,
"b": 483.36
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"text": "Vision problems? □ Yes □ No",
"children": [
{
"id": "p3.9.1",
"order": 55,
"type": "form_field",
"bbox": {
"l": 417.063762,
"t": 496.66393300000004,
"r": 424.263762,
"b": 484.66393300000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.9",
"text_offset": 17,
"text_span": 1
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},
{
"id": "p3.9.2",
"order": 56,
"type": "form_field",
"bbox": {
"l": 445.339948,
"t": 496.66393300000004,
"r": 452.539948,
"b": 484.66393300000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.9",
"text_offset": 23,
"text_span": 1
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]
},
{
"id": "p3.10",
"order": 57,
"type": "text",
"bbox": {
"l": 328.56,
"t": 476.4,
"r": 483.84,
"b": 462.48
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"text": "Bone/joint injuries? □ Yes □ No",
"children": [
{
"id": "p3.10.1",
"order": 58,
"type": "form_field",
"bbox": {
"l": 429.25712,
"t": 475.66393400000004,
"r": 436.45712,
"b": 463.66393400000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.10",
"text_offset": 21,
"text_span": 1
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},
{
"id": "p3.10.2",
"order": 59,
"type": "form_field",
"bbox": {
"l": 457.533308,
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"r": 464.733308,
"b": 463.66393400000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.10",
"text_offset": 27,
"text_span": 1
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]
},
{
"id": "p3.11",
"order": 60,
"type": "text",
"bbox": {
"l": 328.8,
"t": 455.52,
"r": 494.88,
"b": 441.36
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"text": "Missing paired organ? □ Yes □ No",
"children": [
{
"id": "p3.11.1",
"order": 61,
"type": "form_field",
"bbox": {
"l": 440.243448,
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"r": 447.443448,
"b": 442.66393500000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.11",
"text_offset": 22,
"text_span": 1
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},
{
"id": "p3.11.2",
"order": 62,
"type": "form_field",
"bbox": {
"l": 468.519637,
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"r": 475.719637,
"b": 442.66393500000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.11",
"text_offset": 28,
"text_span": 1
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]
},
{
"id": "p3.12",
"order": 63,
"type": "text",
"bbox": {
"l": 328.56,
"t": 434.4,
"r": 479.04,
"b": 420.24
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"text": "Asthma diagnosis? □ Yes □ No",
"children": [
{
"id": "p3.12.1",
"order": 64,
"type": "form_field",
"bbox": {
"l": 423.884074,
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"r": 431.084074,
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.12",
"text_offset": 18,
"text_span": 1
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},
{
"id": "p3.12.2",
"order": 65,
"type": "form_field",
"bbox": {
"l": 452.16026,
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"r": 459.36026,
"b": 421.66393600000004
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.12",
"text_offset": 24,
"text_span": 1
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]
},
{
"id": "p3.13",
"order": 66,
"type": "text",
"bbox": {
"l": 328.8,
"t": 413.52,
"r": 461.52,
"b": 399.36
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"text": "Use of inhaler? □ Yes □ No",
"children": [
{
"id": "p3.13.1",
"order": 67,
"type": "form_field",
"bbox": {
"l": 406.575481,
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.13",
"text_offset": 16,
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},
{
"id": "p3.13.2",
"order": 68,
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"l": 434.851667,
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"text": "",
"attrs": {
"field_kind": "checkbox",
"label": "No",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.13",
"text_offset": 22,
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]
},
{
"id": "p3.14",
"order": 69,
"type": "text",
"bbox": {
"l": 329.04,
"t": 392.4,
"r": 436.56,
"b": 378.72
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"text": "Diabetes? □ Yes □ No",
"children": [
{
"id": "p3.14.1",
"order": 70,
"type": "form_field",
"bbox": {
"l": 381.427045,
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"text": "",
"attrs": {
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"label": "Yes",
"source": "glyph",
"label_source": "parent_text",
"label_ref": "p3.14",
"text_offset": 10,
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},
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"bbox": {
"l": 409.703231,
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"text": "",
"attrs": {
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"label": "No",
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"label_ref": "p3.14",
"text_offset": 16,
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},
{
"id": "p3.15",
"order": 72,
"type": "text",
"bbox": {
"l": 329.04,
"t": 371.52,
"r": 446.64,
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"text": "Use insulin? □ Yes □ No",
"children": [
{
"id": "p3.15.1",
"order": 73,
"type": "form_field",
"bbox": {
"l": 391.721966,
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"text": "",
"attrs": {
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"label": "Yes",
"source": "glyph",
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"label_ref": "p3.15",
"text_offset": 13,
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},
{
"id": "p3.15.2",
"order": 74,
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"bbox": {
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"text": "",
"attrs": {
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"label": "No",
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]
},
{
"id": "p3.16",
"order": 75,
"type": "text",
"bbox": {
"l": 329.04,
"t": 350.16,
"r": 452.88,
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"text": "Tobacco use? □ Yes □ No",
"children": [
{
"id": "p3.16.1",
"order": 76,
"type": "form_field",
"bbox": {
"l": 397.997356,
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"r": 405.197356,
"b": 337.663939
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"text": "",
"attrs": {
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"label": "Yes",
"source": "glyph",
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"label_ref": "p3.16",
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},
{
"id": "p3.16.2",
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"bbox": {
"l": 426.273542,
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"attrs": {
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"label": "No",
"source": "glyph",
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"label_ref": "p3.16",
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]
},
{
"id": "p3.17",
"order": 78,
"type": "text",
"bbox": {
"l": 328.8,
"t": 329.52,
"r": 561.84,
"b": 315.12
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"text": "Family history of sickle-cell anemia? □ Yes □ No",
"children": [
{
"id": "p3.17.1",
"order": 79,
"type": "form_field",
"bbox": {
"l": 507.649693,
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"label": "Yes",
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},
{
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"label": "No",
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},
{
"id": "p3.18",
"order": 81,
"type": "text",
"bbox": {
"l": 328.56,
"t": 308.64,
"r": 512.16,
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"text": "Other medical problems? □ Yes □ No",
"children": [
{
"id": "p3.18.1",
"order": 82,
"type": "form_field",
"bbox": {
"l": 456.649698,
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"attrs": {
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},
{
"id": "p3.18.2",
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"bbox": {
"l": 484.925883,
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"r": 492.125883,
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},
{
"id": "p3.19",
"order": 84,
"type": "text",
"bbox": {
"l": 328.8,
"t": 287.52,
"r": 496.32,
"b": 272.88
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"text": "Injury in the last year? □ Yes □ No",
"children": [
{
"id": "p3.19.1",
"order": 85,
"type": "form_field",
"bbox": {
"l": 441.427042,
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"attrs": {
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"label": "Yes",
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},
{
"id": "p3.19.2",
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"l": 469.703227,
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]
},
{
"id": "p3.20",
"order": 87,
"type": "text",
"bbox": {
"l": 38.16,
"t": 253.44,
"r": 208.32,
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"text": "Loss of consciousness? □ Yes □ No",
"children": [
{
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"order": 88,
"type": "form_field",
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},
{
"id": "p3.20.2",
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},
{
"id": "p3.21",
"order": 90,
"type": "text",
"bbox": {
"l": 38.4,
"t": 232.56,
"r": 198.96,
"b": 219.36
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"text": "Seizures or epilepsy? □ Yes □ No",
"children": [
{
"id": "p3.21.1",
"order": 91,
"type": "form_field",
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"attrs": {
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},
{
"id": "p3.21.2",
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},
{
"id": "p3.22",
"order": 93,
"type": "text",
"bbox": {
"l": 38.64,
"t": 211.44,
"r": 171.12,
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"text": "Nerve injuries? □ Yes □ No",
"children": [
{
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"order": 94,
"type": "form_field",
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},
{
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Page 6
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1 · FIGURE
2 · HEADER
3 · TITLE
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5
6 · HEADING
7 · TEXT
8 · HEADING
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11
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20 · HEADING
21 · LIST
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