{"id":1047,"date":"2025-02-18T11:51:42","date_gmt":"2025-02-18T11:51:42","guid":{"rendered":"https:\/\/www.parkhousespa.co.uk\/?page_id=1047"},"modified":"2025-02-18T11:58:53","modified_gmt":"2025-02-18T11:58:53","slug":"aquatic-therapy-evaluation-form","status":"publish","type":"page","link":"https:\/\/www.parkhousespa.co.uk\/?page_id=1047","title":{"rendered":"4 Aquatic Therapy Evaluation Form"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-dae0baa6-556c-4871-b2fb-6c7830b96c64\" id=\"wpforms-1036\"><form id=\"wpforms-form-1036\" class=\"wpforms-validate wpforms-form\" data-formid=\"1036\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1047\" data-token=\"f385a1f8e9aa28fa4891487be71c774e\" data-token-time=\"1777642653\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-1036-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\">Patient Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1036-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-1036-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1036-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-1036-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1036-field_43-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_43\">Patient Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" required><div class=\"wpforms-field-description\">DDMMYYYY<\/div><\/div><div id=\"wpforms-1036-field_21-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_21\">Phone Number<\/label><input type=\"number\" id=\"wpforms-1036-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" step=\"any\" ><\/div><div id=\"wpforms-1036-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1036-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1036-field_22-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"22\"><label class=\"wpforms-field-label\">Please advise whether initial assessment or follow up <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1036-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_22_1\" name=\"wpforms[fields][22][]\" value=\"Initial Assessment\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_22_1\">Initial Assessment<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_22_2\" name=\"wpforms[fields][22][]\" value=\"Follow Up Evaluation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_22_2\">Follow Up Evaluation<\/label><\/li><\/ul><\/div><div id=\"wpforms-1036-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_23\">Name of Person Completing Form <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-1036-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_24\">Relationship to Patient <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-1036-field_44-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_44\">Date of Completion <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" required><div class=\"wpforms-field-description\">DMMYYYY<\/div><\/div><div id=\"wpforms-1036-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_27\">Please state your symptom (physical or mental), which bothers you the most <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-1036-field_9-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_9\">Symptom 1 Please consider how bad this symptom has been, over the last week, and score it by choosing a number (0 &#8211; no impact, 6 \u2013 maximum impact)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-1036-field_32-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"32\"><label class=\"wpforms-field-label\">For how long have you had Symptom 1?<\/label><ul id=\"wpforms-1036-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_32_1\" name=\"wpforms[fields][32][]\" value=\"0-4 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_32_1\">0-4 weeks<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_32_2\" name=\"wpforms[fields][32][]\" value=\"4-12 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_32_2\">4-12 weeks<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_32_3\" name=\"wpforms[fields][32][]\" value=\"3 months-1 year\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_32_3\">3 months-1 year<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_32_4\" name=\"wpforms[fields][32][]\" value=\"1-5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_32_4\">1-5 years<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_32_5\" name=\"wpforms[fields][32][]\" value=\"Over 5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_32_5\">Over 5 years<\/label><\/li><\/ul><\/div>\t\t<div id=\"wpforms-1036-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1036-field_2\" >no 6 Email<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1036-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-1036-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_30\">Please state your next symptom (physical or mental)<\/label><input type=\"text\" id=\"wpforms-1036-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-1036-field_31-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_31\">Symptom 2 Please consider how this symptom has been, over the last week, and score it by choosing a number (0 &#8211; no impact, 6 \u2013 maximum impact) (copy)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-1036-field_33-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"33\"><label class=\"wpforms-field-label\">For how long have you had Symptom 2?<\/label><ul id=\"wpforms-1036-field_33\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_33_1\" name=\"wpforms[fields][33][]\" value=\"0-4 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_33_1\">0-4 weeks<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_33_2\" name=\"wpforms[fields][33][]\" value=\"4-12 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_33_2\">4-12 weeks<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_33_3\" name=\"wpforms[fields][33][]\" value=\"3 months-1 year\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_33_3\">3 months-1 year<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_33_4\" name=\"wpforms[fields][33][]\" value=\"1-5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_33_4\">1-5 years<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_33_5\" name=\"wpforms[fields][33][]\" value=\"Over 5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_33_5\">Over 5 years<\/label><\/li><\/ul><\/div><div id=\"wpforms-1036-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_34\">Please state your next symptom (physical or mental)<\/label><input type=\"text\" id=\"wpforms-1036-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/div><div id=\"wpforms-1036-field_35-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_35\">Symptom 3 Please consider how this symptom has been, over the last week, and score it by choosing a number (0 &#8211; no impact, 6 \u2013 maximum impact)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-1036-field_36-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"36\"><label class=\"wpforms-field-label\">For how long have you had Symptom 3?<\/label><ul id=\"wpforms-1036-field_36\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_36_1\" name=\"wpforms[fields][36][]\" value=\"0-4 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_36_1\">0-4 weeks<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_36_2\" name=\"wpforms[fields][36][]\" value=\"4-12 weeks\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_36_2\">4-12 weeks<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_36_3\" name=\"wpforms[fields][36][]\" value=\"3 months-1 year\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_36_3\">3 months-1 year<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_36_4\" name=\"wpforms[fields][36][]\" value=\"1-5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_36_4\">1-5 years<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1036-field_36_5\" name=\"wpforms[fields][36][]\" value=\"Over 5 years\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1036-field_36_5\">Over 5 years<\/label><\/li><\/ul><\/div><div id=\"wpforms-1036-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_39\">Please choose an activity (physical, social or mental) that is important for you, that your problem makes difficult or prevents you doing.  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1036-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" required><\/div><div id=\"wpforms-1036-field_37-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_37\">Score how bad it has been in the last week  (0 &#8211; no impact, 6 \u2013 maximum impact)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-1036-field_38-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_38\">Please choose another activity (physical, social or mental) that is important for you, that your problem makes difficult or prevents you doing. <\/label><input type=\"text\" id=\"wpforms-1036-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-1036-field_40-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_40\">Score how bad it has been in the last week (0 &#8211; no impact, 6 \u2013 maximum impact)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-1036-field_42-container\" class=\"wpforms-field wpforms-field-number-slider\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-1036-field_42\">Please rate your general feeling of well-being during last week (0 &#8211; no impact, 6 \u2013 maximum impact)<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-1036-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" value=\"0\"\t\tmin=\"0\"\n\tmax=\"6\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-1036-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-1036-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-1036-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"1036\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/1047\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1036\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":179,"menu_order":4,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1047","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/1047","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1047"}],"version-history":[{"count":3,"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/1047\/revisions"}],"predecessor-version":[{"id":1051,"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/1047\/revisions\/1051"}],"up":[{"embeddable":true,"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=\/wp\/v2\/pages\/179"}],"wp:attachment":[{"href":"https:\/\/www.parkhousespa.co.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1047"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}