Medical Questionnaire Form.json

{
    "pc": {
        "type": "Grid",
        "model": {
            "stacked": "md",
            "frame": {
                "horizontal": null,
                "vertical": null,
                "radius": null
            },
            "border": {
                "width": null,
                "color": null
            },
            "rows": [{
                "cells": [{
                    "padding": [null, null, 10, null],
                    "component": {
                        "type": "Text",
                        "model": {
                            "_internalName": "Text1",
                            "text": "<h6 style=\"text-align:left;\"><strong>MEDICAL GROUP</strong></h6><h6 style=\"text-align:left;\"><strong>Healthcare Service</strong></h6>",
                            "class": "company-name bg-primary"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 4
                    }
                }, {
                    "component": {
                        "type": "Text",
                        "model": {
                            "_internalName": "Text5",
                            "width": 600,
                            "text": "<h1 style=\"text-align:left;\">Medical Questionnaire<br /></h1><p style=\"text-align:left;\">Please provide complete and honest responses in the questionnaire. Accurate information is crucial for understanding your medical history and providing personalized care. </p><p style=\"text-align:left;\">Thank you for your cooperation!</p>",
                            "class": "header"
                        }
                    },
                    "alignment": {
                        "horizontal": "Left",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 8
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading1",
                            "heading": "Patient Details",
                            "view": "Normal",
                            "font": {
                                "color": "",
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": 5,
                                "vertical": 10,
                                "radius": null
                            },
                            "class": "bg-primary",
                            "fill": "#bfd3d0",
                            "size": "H3",
                            "textAlignment": "Left"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "FullName",
                            "title": {
                                "text": "Full Name",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 5
                    }
                }, {
                    "component": {
                        "type": "Date",
                        "model": {
                            "_internalName": "DateOfBirth",
                            "title": {
                                "text": "Date of Birth",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": true,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            }
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 5
                    }
                }, {
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "Age",
                            "title": {
                                "text": "Age",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "description": "Select date of birth",
                            "class": "age",
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 2
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "MultiLineText",
                        "model": {
                            "_internalName": "Address",
                            "title": {
                                "text": "Address",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mode": "Plain"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "MaskedInput",
                        "model": {
                            "_internalName": "PhoneMobile1",
                            "title": {
                                "text": "Phone - Mobile",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mask": "000-0000-0000"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "component": {
                        "type": "MaskedInput",
                        "model": {
                            "_internalName": "PhoneHome1",
                            "title": {
                                "text": "Phone - Home",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mask": "000-0000-0000"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "Email",
                            "title": {
                                "text": "Email",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cHint": "username@domain.com",
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "E-mail",
                            "pattern": "^[^@\\s]+@[^@\\s]+\\.[^@\\s]+$",
                            "error": "This field must contain a valid e-mail address."
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading2",
                            "heading": "Insurance Information",
                            "view": "Normal",
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": 10,
                                "radius": null
                            },
                            "class": "bg-primary",
                            "fill": "#bfd3d0",
                            "size": "H3",
                            "textAlignment": "Left"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "Insurance",
                            "title": {
                                "text": "Do you have Health Insurance?",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "Yes\nNo",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "Yes\nNo",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 4
                    }
                }]
            }, {
                "cells": [{
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "InsuranceProvider",
                            "title": {
                                "text": "Insurance Provider",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "HealthFundName",
                            "title": {
                                "text": "Health Fund Name",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "MembershipNumber",
                            "title": {
                                "text": "Membership Number",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "Reference Number",
                            "title": {
                                "text": "Reference Number",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "LevelInsurance",
                            "title": {
                                "text": "Level of the Insurance Coverage",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "class": "insurance",
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "InsuranceDate",
                            "title": {
                                "text": "Insurance Start Date ",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "class": "insurance",
                    "component": {
                        "type": "Number",
                        "model": {
                            "_internalName": "Excess",
                            "title": {
                                "text": "Insurance Excess",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "min": 0,
                            "precision": "0",
                            "percents": false,
                            "spinButtons": true,
                            "step": 1
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading3",
                            "heading": "Emergency Contacts",
                            "view": "Normal",
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": 10,
                                "radius": null
                            },
                            "class": "bg-primary",
                            "fill": "#bfd3d0",
                            "size": "H3",
                            "textAlignment": "Left"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "EmergencyContactFullName",
                            "title": {
                                "text": "Full Name",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "EmergencyContactRelationship",
                            "title": {
                                "text": "Relationship",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "MaskedInput",
                        "model": {
                            "_internalName": "Phone",
                            "title": {
                                "text": "Phone",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mask": "000-0000-0000"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "component": {
                        "type": "SingleLineText",
                        "model": {
                            "_internalName": "EmergencyContactEmail",
                            "title": {
                                "text": "Email",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "type": "Anything"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading4",
                            "heading": "Medical Data",
                            "view": "Normal",
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": 10,
                                "radius": null
                            },
                            "class": "bg-primary",
                            "fill": "#bfd3d0",
                            "size": "H3",
                            "textAlignment": "Left"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "Number",
                        "model": {
                            "_internalName": "Height",
                            "title": {
                                "text": "Height (ft)",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "min": 0,
                            "precision": "0",
                            "percents": false,
                            "spinButtons": true,
                            "step": 1
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "component": {
                        "type": "Number",
                        "model": {
                            "_internalName": "Weight",
                            "width": 180,
                            "title": {
                                "text": "Weight (lb)",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "min": 0,
                            "precision": "0",
                            "percents": false,
                            "spinButtons": true,
                            "step": 1
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "MultiLineText",
                        "model": {
                            "_internalName": "ALLMEDICALCONDITIONS",
                            "title": {
                                "text": "All confirmed Medical Conditions ",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mode": "Plain"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "MultiLineText",
                        "model": {
                            "_internalName": "FamilyHistory",
                            "title": {
                                "text": "Relevant Family History",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mode": "Plain"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "Medications",
                            "title": {
                                "text": "Are you taking any medications on a regular or occasional basis?",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "Yes\nNo",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "Yes\nNo",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "DataTable",
                        "model": {
                            "_internalName": "MedicationsList",
                            "title": {
                                "text": "List all medications you're taking ",
                                "visible": true
                            },
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "newLine": "Top",
                            "delete": "Last",
                            "columns": [{
                                "_internalName": "MedicationName",
                                "title": "Medication name",
                                "required": false,
                                "type": "String"
                            }, {
                                "_internalName": "Dosage",
                                "title": "Dosage(mg)",
                                "required": false,
                                "type": "Number",
                                "step": 1,
                                "spinButtons": true,
                                "percents": false,
                                "precision": 0,
                                "min": 0
                            }, {
                                "_internalName": "FrequencyDay",
                                "title": "How often on a daily basis?",
                                "required": false,
                                "type": "Dropdown",
                                "selection": "Single",
                                "allowUserValue": true,
                                "options": "1 time\n2 times\n3 times\n"
                            }]
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "AllergicOnMedications",
                            "title": {
                                "text": "Are you allergic to any medications? ",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "Yes\nNo",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "Yes\nNo",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "MultiLineText",
                        "model": {
                            "_internalName": "AllergicOnMedicationsList",
                            "title": {
                                "text": "Please write medications you are allergic to:",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mode": "Plain"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "AllergicFood",
                            "title": {
                                "text": "Are you allergic to any food or anything else?",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "Yes\nNo",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "Yes\nNo",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "MultiLineText",
                        "model": {
                            "_internalName": "AllergicFoodList",
                            "title": {
                                "text": "Please write on what are you allergic and what kind of reaction you had (rash, itching, strangling, heart failure, shock and similar)",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "mode": "Plain"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "AreYouASmoker",
                            "title": {
                                "text": "Are you a smoker?",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "Yes\nNo",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "Yes\nNo",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }, {
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "Number",
                        "model": {
                            "_internalName": "SmokingDaily",
                            "title": {
                                "text": "How much are you smoking on daily basis?",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "min": 0,
                            "precision": "0",
                            "percents": false,
                            "spinButtons": true,
                            "step": 1
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [10, null, null, null],
                    "component": {
                        "type": "SingleChoice",
                        "model": {
                            "_internalName": "AreYouDrinkingAlcohol",
                            "title": {
                                "text": "Are you drinking alcohol? ",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            },
                            "dataSource": "StaticList",
                            "StaticList": {
                                "options": "No\nOccasionally\nOften",
                                "allowUserValue": false
                            },
                            "cColumns": 1,
                            "options": "No\nOccasionally\nOften",
                            "allowUserValue": false
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading5",
                            "heading": "Surgical History",
                            "view": "Normal",
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": 10,
                                "radius": null
                            },
                            "class": "bg-primary",
                            "fill": "#bfd3d0",
                            "size": "H3",
                            "textAlignment": "Left"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "DataTable",
                        "model": {
                            "_internalName": "SurgicalHistory",
                            "title": {
                                "text": "Surgical History",
                                "visible": false
                            },
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "newLine": "Top",
                            "delete": "Last",
                            "columns": [{
                                "_internalName": "Type",
                                "title": "Type of surgery ",
                                "required": false,
                                "type": "Dropdown",
                                "selection": "Single",
                                "allowUserValue": true,
                                "options": "Appendectomy\nBrain surgery\nBreast surgery\nCABG\nCholecystectomy\nColon surgery\nTonsillectomy\nAppendectomy\nThyroid surgery\nLung surgery\nC-section\nEye surgery\nFracture surgery\nHernia repair\nHysterectomy\nJoint surgery\nBunionectomy\nVaricose vein surgery\nProstate surgery\nWeight reduction surgery\nSmall intestine surgery\nSpine surgery\nTubal ligation\nValve replacement\nVasectomy\nVascular surgery\nCardiac stent\nBladder surgery"
                            }, {
                                "_internalName": "Date",
                                "title": "Date of surgery ",
                                "required": false,
                                "type": "String"
                            }]
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Heading",
                        "model": {
                            "_internalName": "Heading6",
                            "heading": "",
                            "view": "Line",
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "frame": {
                                "horizontal": null,
                                "vertical": null,
                                "radius": null
                            },
                            "size": "H4",
                            "textAlignment": "Center"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "Date",
                        "model": {
                            "_internalName": "CompletionDate",
                            "width": 150,
                            "title": {
                                "text": "Completion Date",
                                "visible": false
                            },
                            "orientation": "Horizontal",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "class": "completion-date",
                            "cWidth": 250,
                            "cFont": {
                                "style": "Normal",
                                "weight": "Normal"
                            }
                        }
                    },
                    "alignment": {
                        "horizontal": "Left",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "Text",
                        "model": {
                            "_internalName": "Text4",
                            "width": 600,
                            "text": "<p style=\"text-align:left;\">I state that I fully understood all the questions, received needed explanations and that the data in this questionnaire is authentic.</p>"
                        }
                    },
                    "alignment": {
                        "horizontal": "Left",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 6
                    }
                }]
            }, {
                "cells": [{
                    "component": {
                        "type": "Signature",
                        "model": {
                            "_internalName": "Signature",
                            "title": {
                                "text": "",
                                "visible": true
                            },
                            "orientation": "Vertical",
                            "required": false,
                            "font": {
                                "style": "Normal",
                                "weight": "Semibold"
                            },
                            "wrap": true,
                            "cWidth": 300,
                            "height": 150,
                            "inkColor": "#000000"
                        }
                    },
                    "alignment": {
                        "horizontal": "Left",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }, {
                "cells": [{
                    "padding": [20, null, null, null],
                    "component": {
                        "type": "Submit",
                        "model": {
                            "_internalName": "Submit1",
                            "text": "SUBMIT",
                            "savingText": "Submitting...",
                            "type": "Primary",
                            "click": "return fd.save();"
                        }
                    },
                    "alignment": {
                        "horizontal": "Justify",
                        "vertical": "Top"
                    },
                    "columns": {
                        "width": 12
                    }
                }]
            }]
        }
    },
    "tablet": null,
    "phone": null,
    "js": "//detect theme change\r\nfd.themeChanged = theme => {\r\n    $('.fd-form').attr('theme', theme);\r\n};\r\n\r\nfd.rendered(function() {\r\n    //disable fields\r\n    fd.field('Age').disabled = true;\r\n    fd.field('CompletionDate').disabled = true;\r\n    //set CompletionDate to the current date\r\n    fd.field('CompletionDate').value = new Date();\r\n\r\n    //call functions when changing field values\r\n    fd.field('Medications').$on('change', showHideMedicationsList);\r\n    fd.field('Insurance').$on('change', showHideInsuranceFields);\r\n    fd.field('AllergicOnMedications').$on('change', showHideAllergicOnMedicationsList);\r\n    fd.field('AllergicFood').$on('change', showHideAllergicFood);\r\n    fd.field('AreYouASmoker').$on('change', showHideSmokingDaily);\r\n    fd.field('DateOfBirth').$on('change', ageDescription);\r\n\r\n    //сalling functions on form loading\r\n    showHideMedicationsList();\r\n    showHideInsuranceFields();\r\n    showHideAllergicFood();\r\n    showHideSmokingDaily();\r\n    showHideAllergicOnMedicationsList();\r\n    ageDescription();\r\n\r\n    //load the Moment.js library to calculate patient's age and disable dates\r\n    $.getScript('https://cdnjs.cloudflare.com/ajax/libs/moment.js/2.24.0/moment-with-locales.min.js')\r\n        .then(function() {\r\n            calculateAge();\r\n            fd.field('DateOfBirth').$on('change', calculateAge);\r\n            calendarSetUp();\r\n\r\n        });\r\n});\r\n\r\n//show/hide Age field description\r\nfunction ageDescription () {\r\n    if(!fd.field('DateOfBirth').value){\r\n    fd.field('Age').description = 'Select date of birth'\r\n    }\r\n    else {\r\n        fd.field('Age').description = ''\r\n    }\r\n}\r\n\r\n\r\n//show/hide insurance details\r\nfunction showHideInsuranceFields() {\r\n    if (fd.field('Insurance').value == 'Yes') {\r\n        $('.insurance').show();\r\n    } else {\r\n        $('.insurance').hide();\r\n    }\r\n}\r\n\r\n//show/hide medications list\r\nfunction showHideMedicationsList() {\r\n    if (fd.field('Medications').value == 'Yes') {\r\n        fd.control('MedicationsList').hidden = false;\r\n    } else {\r\n        fd.control('MedicationsList').hidden = true;\r\n    }\r\n}\r\n\r\n//show hide AllergicOnMedicationsList field\r\nfunction showHideAllergicOnMedicationsList() {\r\n    if (fd.field('AllergicOnMedications').value == 'Yes') {\r\n        fd.field('AllergicOnMedicationsList').hidden = false;\r\n    } else {\r\n        fd.field('AllergicOnMedicationsList').hidden = true;\r\n    }\r\n}\r\n\r\n//show hide AllergicFoodList field\r\nfunction showHideAllergicFood() {\r\n    if (fd.field('AllergicFood').value == 'Yes') {\r\n        fd.field('AllergicFoodList').hidden = false;\r\n    } else {\r\n        fd.field('AllergicFoodList').hidden = true;\r\n    }\r\n}\r\n\r\n//show hide SmokingDaily field\r\nfunction showHideSmokingDaily() {\r\n    if (fd.field('AreYouASmoker').value == 'Yes') {\r\n        fd.field('SmokingDaily').hidden = false;\r\n    } else {\r\n        fd.field('SmokingDaily').hidden = true;\r\n    }\r\n}\r\n\r\n//calculate patient's age\r\nfunction calculateAge() {\r\n    if (fd.field('DateOfBirth').value) {\r\n        var purchase = moment(fd.field('DateOfBirth').value);\r\n        var delivery = moment(new Date());\r\n        var dateDiff = delivery.diff(purchase, 'years', false);\r\n        fd.field('Age').value = dateDiff;\r\n    } else {\r\n        fd.field('Age').value = '';\r\n    }\r\n}\r\n\r\n//disable dates to allow only 18+ users\r\n//set up calendar start view\r\nfunction calendarSetUp() {\r\n    var today = moment(new Date());\r\n    var newDate = today.subtract(18, 'years');\r\n    fd.field('DateOfBirth').widgetOptions = {\r\n        max: moment(newDate).toDate(),\r\n        start: 'decade'\r\n    }\r\n}",
    "css": "/* setting the Heading background depending on the theme */\n.fd-form h3 > span {\n    background-color: var(--fd-primary-rgb) !important;\n}\n\n/** styling of the disable Age field **/\n.fd-form .age .form-control:disabled {\n    background-color: transparent;\n    border: none;\n}\n\n/** styling of the disable Date field **/\n.fd-form .completion-date .form-control:disabled,\n.fd-form .completion-date .form-control[readonly],\n.fd-form .completion-date .k-datepicker .k-picker-wrap,\n.fd-form .completion-date  .form-control{\n    background-color: transparent;\n    border: none;\n    font-weight: bold;\n    padding-left: 0px;\n}\n\n.fd-form .completion-date .k-select {\n    display: none !important;\n}\n\n/* styling for the hospital name */\n.fd-form .company-name {\n    border-left: solid 15px;\n    padding: 25px\n}\n\n.fd-form .company-name h6 {    \n    margin-top: 0;\n    margin-bottom: 5px;\n    padding-left: 10px;\n}\n\n/* changing the styling of the hospital name and section headers when theme changes*/\n\n/****** THEME 1 ******/\n\n.fd-form .company-name {\n    border-left-color: #1a1a1a;\n}\n\n.fd-form .company-name h6,\n.fd-form h3{    \n    color: #4f4d4d;\n}\n\n.fd-form h3::before {\n    content: ' /';\n}\n\n\n/****** THEME 2 ******/\n\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] .company-name,\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] .fd-heading.bg-primary {\n    border-left-color: #3d9e87;\n}\n\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] .company-name h6 {    \n    color: #ffffff;\n}\n\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] h3 {\n    color: #ffffff;\n}\n\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] .fd-heading {\n    border-left: solid 15px;\n}\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5']  .fd-heading::before,\n.fd-form[theme='d3d0e45fe35e8efafd7c37a2b012a5c5'] h3::before{\n    content: none;\n}\n\n\n/****** THEME 3 ******/\n.fd-form[theme='blue'] .company-name {\n    border-left-color: #1a1a1a;\n}\n\n.fd-form[theme='blue']  .company-name h6,\n.fd-form[theme='blue']  h3{    \n    color: #ffffff;\n}\n\n.fd-form[theme='blue']  h3::before {\n    content: ' #';\n}\n\n\n/****** THEME 4 ******/\n\n.fd-form[theme='purple'] .company-name,\n.fd-form[theme='purple'] .fd-heading.bg-primary{\n    border-left-color: #F7C200;\n}\n\n.fd-form[theme='purple'] .company-name h6,\n.fd-form[theme='purple'] h3{    \n    color: #ffffff;\n}\n\n\n.fd-form[theme='purple'] .fd-heading {\n    border-left: solid 15px;\n}\n\n.fd-form[theme='purple']  .fd-heading::before,\n.fd-form[theme='purple']  h3::before{\n    content: none;\n}\n",
    "notifySubscribers": false,
    "version": "1.0.2",
    "theme": {
        "primary": "#bfd3d0",
        "bodyText": "#1a1a1a",
        "bodyBackground": "#f2efea",
        "fontFamily": "Marcellus",
        "fontType": 1,
        "fontSize": 16,
        "fontWeight": 400,
        "borderThickness": 1,
        "borderRadius": 2,
        "shadow": true,
        "themeId": "4451878ec1bcf39b5f21fa18520fade3"
    },
    "timezone": "America/Los_Angeles",
    "culture": "en",
    "userLanguage": null,
    "userCulture": null,
    "thankYouMessage": null,
    "redirectURL": null,
    "hideAfterSubmission": false,
    "submissionTimeout": 0,
    "authentication": 0,
    "singleSubmissionPerUser": false,
    "allowEditingSubmission": false,
    "restrictAccess": false,
    "azureADTenant": null,
    "azureADObjects": [],
    "azureB2CProperties": null
}