{ "document_id": 16666, "page": 3, "width_pt": 612, "height_pt": 792, "rotation": 0, "pipeline_version": "paddleocr-vl-1.6+paul-48", "engine": "paddleocr_vl", "source_run_id": 16778, "item_count": 119, "counts_by_type": { "figure": 1, "footer": 1, "form_field": 72, "header": 1, "heading": 3, "list": 2, "list_item": 18, "text": 20, "title": 1 }, "build_ms": 10, "items": [ { "id": "p3.1", "order": 1, "type": "figure", "bbox": { "l": 41.28, "t": 752.16, "r": 156.96, "b": 691.2 }, "text": "", "attrs": { "role": "page_header", "block_label": "header_image" } }, { "id": "p3.2", "order": 2, "type": "header", "bbox": { "l": 172.32, "t": 747.36, "r": 476.16, "b": 715.92 }, "text": "KENTUCKY STATE UNIVERSITY\nCooperative Extension Program 4-H Youth Development", "attrs": { "block_label": "header" }, "level": 2 }, { "id": "p3.3", "order": 3, "type": "title", "bbox": { "l": 171.84, "t": 706.56, "r": 436.32, "b": 665.04 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "attrs": { "block_label": "doc_title" }, "level": 2 }, { "id": "p3.4", "order": 4, "type": "text", "bbox": { "l": 40.8, "t": 634.56, "r": 311.52, "b": 621.6 }, "text": "PARTICIPANTNAME:___", "children": [ { "id": "p3.4.1", "order": 5, "type": "form_field", "bbox": { "l": 43.2474, "t": 633.9335, "r": 310.278, "b": 621.9335 }, "text": "", "attrs": { "field_kind": "text", "label": "PARTICIPANTNAME:___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p3.4" } } ] }, { "id": "p3.5", "order": 6, "type": "heading", "bbox": { "l": 40.56, "t": 583.44, "r": 344.64, "b": 568.8 }, "text": "SECTION 3. HEALTH HISTORY (Please check Yes or No)", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p3.6", "order": 7, "type": "list", "bbox": { "l": 37.92, "t": 547.44, "r": 281.04, "b": 261.36 }, "text": "", "attrs": { "item_count": 14 }, "children": [ { "id": "p3.6.1", "order": 8, "type": "list_item", "bbox": { "l": 38.16, "t": 547.44, "r": 216.48, "b": 534.24 }, "text": "Hospitalized in the past? □ Yes □ No", "children": [ { "id": "p3.6.1.1", "order": 9, "type": "form_field", "bbox": { "l": 162.254342, "t": 546.845053, "r": 169.454342, "b": 534.845054 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.1", "text_offset": 26, "text_span": 1 } }, { "id": "p3.6.1.2", "order": 10, "type": "form_field", "bbox": { "l": 190.530526, "t": 546.845053, "r": 197.730526, "b": 534.845054 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.1", "text_offset": 32, "text_span": 1 } } ] }, { "id": "p3.6.2", "order": 11, "type": "list_item", "bbox": { "l": 38.16, "t": 526.32, "r": 196.56, "b": 513.12 }, "text": "Surgery of any kind? □ Yes □ No", "children": [ { "id": "p3.6.2.1", "order": 12, "type": "form_field", "bbox": { "l": 141.93989, "t": 525.845054, "r": 149.13989, "b": 513.845054 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.2", "text_offset": 21, "text_span": 1 } }, { "id": "p3.6.2.2", "order": 13, "type": "form_field", "bbox": { "l": 170.216079, "t": 525.845054, "r": 177.416079, "b": 513.845054 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.2", "text_offset": 27, "text_span": 1 } } ] }, { "id": "p3.6.3", "order": 14, "type": "list_item", "bbox": { "l": 38.16, "t": 505.44, "r": 243.12, "b": 491.76 }, "text": "Currently taking medications? □ Yes □ No", "children": [ { "id": "p3.6.3.1", "order": 15, "type": "form_field", "bbox": { "l": 188.51606, "t": 504.845055, "r": 195.71606, "b": 492.845055 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.3", "text_offset": 30, "text_span": 1 } }, { "id": "p3.6.3.2", "order": 16, "type": "form_field", "bbox": { "l": 216.792247, "t": 504.845055, "r": 223.992246, "b": 492.845055 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.3", "text_offset": 36, "text_span": 1 } } ] }, { "id": "p3.6.4", "order": 17, "type": "list_item", "bbox": { "l": 38.16, "t": 485.04, "r": 281.04, "b": 470.64 }, "text": "Allergies (medications, food, insects)? □ Yes □ No", "children": [ { "id": "p3.6.4.1", "order": 18, "type": "form_field", "bbox": { "l": 226.824652, "t": 483.845056, "r": 234.024652, "b": 471.845056 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.4", "text_offset": 40, "text_span": 1 } }, { "id": "p3.6.4.2", "order": 19, "type": "form_field", "bbox": { "l": 255.100836, "t": 483.845056, "r": 262.300836, "b": 471.845056 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.4", "text_offset": 46, "text_span": 1 } } ] }, { "id": "p3.6.5", "order": 20, "type": "list_item", "bbox": { "l": 38.4, "t": 463.68, "r": 215.52, "b": 450.24 }, "text": "Fainted during exercise? □ Yes □ No", "children": [ { "id": "p3.6.5.1", "order": 21, "type": "form_field", "bbox": { "l": 160.818796, "t": 462.845057, "r": 168.018795, "b": 450.845057 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.5", "text_offset": 25, "text_span": 1 } }, { "id": "p3.6.5.2", "order": 22, "type": "form_field", "bbox": { "l": 189.094985, "t": 462.845057, "r": 196.294985, "b": 450.845057 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.5", "text_offset": 31, "text_span": 1 } } ] }, { "id": "p3.6.6", "order": 23, "type": "list_item", "bbox": { "l": 38.16, "t": 442.8, "r": 262.56, "b": 429.36 }, "text": "Dizziness during or after exercise? □ Yes □ No", "children": [ { "id": "p3.6.6.1", "order": 24, "type": "form_field", "bbox": { "l": 208.121528, "t": 441.845057, "r": 215.321528, "b": 429.845058 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.6", "text_offset": 36, "text_span": 1 } }, { "id": "p3.6.6.2", "order": 25, "type": "form_field", "bbox": { "l": 236.397727, "t": 441.845057, "r": 243.597726, "b": 429.845058 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.6", "text_offset": 42, "text_span": 1 } } ] }, { "id": "p3.6.7", "order": 26, "type": "list_item", "bbox": { "l": 38.4, "t": 421.44, "r": 269.28, "b": 408 }, "text": "Chest pain during or after exercise? □ Yes □ No", "children": [ { "id": "p3.6.7.1", "order": 27, "type": "form_field", "bbox": { "l": 215.1645, "t": 420.845058, "r": 222.3645, "b": 408.845059 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.7", "text_offset": 37, "text_span": 1 } }, { "id": "p3.6.7.2", "order": 28, "type": "form_field", "bbox": { "l": 243.440691, "t": 420.845058, "r": 250.640691, "b": 408.845059 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.7", "text_offset": 43, "text_span": 1 } } ] }, { "id": "p3.6.8", "order": 29, "type": "list_item", "bbox": { "l": 38.4, "t": 400.56, "r": 200.88, "b": 386.88 }, "text": "High blood pressure? □ Yes □ No", "children": [ { "id": "p3.6.8.1", "order": 30, "type": "form_field", "bbox": { "l": 146.316843, "t": 399.845059, "r": 153.516843, "b": 387.84506 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.8", "text_offset": 21, "text_span": 1 } }, { "id": "p3.6.8.2", "order": 31, "type": "form_field", "bbox": { "l": 174.593027, "t": 399.845059, "r": 181.793026, "b": 387.84506 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.8", "text_offset": 27, "text_span": 1 } } ] }, { "id": "p3.6.9", "order": 32, "type": "list_item", "bbox": { "l": 38.4, "t": 379.44, "r": 173.28, "b": 366.24 }, "text": "Heart murmur? □ Yes □ No", "children": [ { "id": "p3.6.9.1", "order": 33, "type": "form_field", "bbox": { "l": 118.959423, "t": 378.84506, "r": 126.159422, "b": 366.845061 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.9", "text_offset": 14, "text_span": 1 } }, { "id": "p3.6.9.2", "order": 34, "type": "form_field", "bbox": { "l": 147.235609, "t": 378.84506, "r": 154.435608, "b": 366.845061 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.9", "text_offset": 20, "text_span": 1 } } ] }, { "id": "p3.6.10", "order": 35, "type": "list_item", "bbox": { "l": 38.4, "t": 358.56, "r": 226.8, "b": 345.12 }, "text": "Rapid heartbeat episodes? 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□ Yes □ No", "children": [ { "id": "p3.6.13.1", "order": 43, "type": "form_field", "bbox": { "l": 117.371532, "t": 294.84506400000004, "r": 124.571531, "b": 282.84506400000004 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.13", "text_offset": 15, "text_span": 1 } }, { "id": "p3.6.13.2", "order": 44, "type": "form_field", "bbox": { "l": 145.647718, "t": 294.84506400000004, "r": 152.847718, "b": 282.84506400000004 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.13", "text_offset": 21, "text_span": 1 } } ] }, { "id": "p3.6.14", "order": 45, "type": "list_item", "bbox": { "l": 38.88, "t": 274.8, "r": 159.36, "b": 261.36 }, "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 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.14", "text_offset": 13, "text_span": 1 } }, { "id": "p3.6.14.2", "order": 47, "type": "form_field", "bbox": { "l": 133.102797, "t": 273.845064, "r": 140.302796, "b": 261.845065 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.6.14", "text_offset": 19, "text_span": 1 } } ] } ] }, { "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 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.7", "text_offset": 34, "text_span": 1 } }, { "id": "p3.7.2", "order": 50, "type": "form_field", "bbox": { "l": 518.212993, "t": 538.663931, "r": 525.412993, "b": 526.663931 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.7", "text_offset": 40, "text_span": 1 } } ] }, { "id": "p3.8", "order": 51, "type": "text", "bbox": { "l": 328.56, "t": 518.4, "r": 522.24, "b": 504.48 }, "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 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "Yes", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.8", "text_offset": 26, "text_span": 1 } }, { "id": "p3.8.2", "order": 53, "type": "form_field", "bbox": { "l": 495.056744, "t": 517.6639319999999, "r": 502.256744, "b": 505.663932 }, "text": "", "attrs": { "field_kind": "checkbox", "label": "No", "source": "glyph", "label_source": "parent_text", "label_ref": "p3.8", "text_offset": 32, "text_span": 1 } } ] }, { "id": "p3.9", "order": 54, "type": "text", "bbox": { "l": 328.8, "t": 497.52, "r": 472.08, "b": 483.36 }, "text": "Vision problems? 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