143 lines
9.6 KiB
PHP
143 lines
9.6 KiB
PHP
<?php
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$questionArray = [
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"Regarding testosterone abnormality" => [
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"When/why did you become concerned about testosterone abnormality" => "text",
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"When were testosterone levelsfirst measured (levels?)" => "text"
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],
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"When testosterone was first measured had you previously taken or were taking" => [
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"prescription pain medication" => ["radio" => ["yes", "no"]],
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"muscle building supplements or steroids" => ["radio" => ["yes", "no"]],
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"testosterone supplements/medications" => ["radio" => ["yes", "no"]]
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],
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"Regarding sexual function" => [
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"Haslibido (sex drive) changed" => ["radio" => ["yes", "no"]],
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"Has erectile function changed" => ["radio" => ["yes", "no"]],
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"Have you used erection medications (What? How Long? Success?) describe" => "text"
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],
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"Regarding fertility" => [
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"Do you have biological children" => ["radio" => ["yes", "no"]],
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"Have you needed fertility assistance for pregnancy" => ["radio" => ["yes", "no"]],
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"Are you hoping to have more children" => ["radio" => ["yes", "no", "maybe"]]
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],
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"Regarding factors that may indicate a problem that can contribute to testosterone problems have you had" => [
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"Abnormal timing or issues with puberty" => ["radio" => ["yes", "no"]],
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"History of undescended or twisted testicle" => ["radio" => ["yes", "no"]],
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"History of testicular trauma or infections" => ["radio" => ["yes", "no"]],
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"History of brain trauma, concussion, or stroke" => ["radio" => ["yes", "no"]],
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"History of chemotherapy or radiation therapy" => ["radio" => ["yes", "no"]],
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"Issues with snoring" => ["radio" => ["yes", "no"]],
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"Prior Sleep apnea evaluation" => ["radio" => ["yes", "no"]],
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"Family members with low testosterone NO/YES: (Who?)" => "text",
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"Family members with fertility problems NO/YES: (Who?)" => "text"
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],
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"Regarding prostate health" => [
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"Have you a rectal prostate exam NO/YES: If yes, last was when?abnormal?" => "text",
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"Have you had PSA blood testingNO/YES: If yes, last was when? Abnormal?" => "text",
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],
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"<b>PERSONAL MEDICAL HISTORY</b> (indicate if you have the following with YEAR OF DIAGNOSIS)" => [
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"High Blood if yes (Year of Diagnosis/ Details)" => "text",
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"High Cholesterol if yes (Year of Diagnosis/ Details)" => "text",
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"Heart Attack if yes (Year of Diagnosis/ Details)" => "text",
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"Stroke if yes (Year of Diagnosis/ Details)" => "text",
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"Atrial Fibrillation if yes (Year of Diagnosis/ Details)" => "text",
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"Celiac Disease if yes (Year of Diagnosis/ Details)" => "text",
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"Cancer if yes (Year of Diagnosis/ Details)" => "text",
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"Depression / Anxiety if yes (Year of Diagnosis/ Details)" => "text",
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"Kidney Disease if yes (Year of Diagnosis/ Details)" => "text",
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"Kidney Stones if yes (Year of Diagnosis/ Details)" => "text",
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"Osteoporosis if yes (Year of Diagnosis/ Details)" => "text",
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"Broken Bone if yes (Year of Diagnosis/ Details)" => "text",
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"Liver problems/Hepatitis if yes (Year of Diagnosis/ Details)" => "text",
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"Bleeding Problems if yes (Year of Diagnosis/ Details)" => "text",
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"Intestinal Problems if yes (Year of Diagnosis/ Details)" => "text",
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"Thyroid Problem if yes (Year of Diagnosis/ Details)" => "text",
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"Emphysema/COPD if yes (Year of Diagnosis/ Details)" => "text",
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"Asthma if yes (Year of Diagnosis/ Details)" => "text",
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"Smoking if yes (Year of Diagnosis/ Details)" => "text",
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"Alcoholism if yes (Year of Diagnosis/ Details)" => "text",
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"Other Problems " => "text"
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],
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"SURGICAL HISTORY " => [
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"Elevated PSA" => ["radio" => ['yes', 'no']],
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"Trouble passing urine" => ["radio" => ['yes', 'no']],
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"Taking medicine for prostate or male-pattern balding" => ["radio" => ['yes', 'no']],
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"History of anemia" => ["radio" => ['yes', 'no']],
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"Vasectomy" => ["radio" => ['yes', 'no']],
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"Erectile dysfunction" => ["radio" => ['yes', 'no']],
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"Testicular or prostate cancer" => ["radio" => ['yes', 'no']],
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"Prostate enlargement or BPH" => ["radio" => ['yes', 'no']],
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"Kidney disease or decreased kidney function" => ["radio" => ['yes', 'no']],
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"Frequent blood donations" => ["radio" => ['yes', 'no']],
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"Non-cancerous testicular or prostate surgery" => ["radio" => ['yes', 'no']],
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"Severe snoring" => ["radio" => ['yes', 'no']],
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"Taking medicine for high cholesterol" => ["radio" => ['yes', 'no']],
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],
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"Birth Control Method" => [
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"planning pregnancy in the next year" => "checkbox",
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"Depend on partner’s contraception" => "checkbox",
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"Vasectomy" => "checkbox",
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"Condoms" => "checkbox",
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"Other" => "text"
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],
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"Activity Level" => [
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"Low – sedentary" => "checkbox",
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"Moderate – walk/jog/workout infrequently" => "checkbox",
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"Average – walk/jog/workout 1 to 3 times per week" => "checkbox",
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"High – walk/jog/workout regularly 4+ times per week" => "checkbox"
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],
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"SOCIAL HISTORY" => [
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"Tobacco Use" => ["radio" => ["yes", "no", "quit"]],
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"Alcohol Use" => ["radio" => ["yes", "no", "quit"]],
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"Alcohol Use" => ["radio" => ["yes", "no", "quit"]],
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"Marital Status" => ["radio" => ["single", "married", "separated", "domestic partner", "others"]],
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"Sexually Active" => ["radio" => ["yes", "no", "not currently"]],
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"Current partner is" => ["radio" => ["yes", "no", "quit"]],
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"Birth control method (if applicable)" => "text",
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"Retired?" => ["radio" => ["yes", "no"]],
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"Current or Past Occupation" => "text",
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"Current or Past Occupation" => "text"
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],
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"ALLERGIES" => [
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"MEDICATION ALLERGIES / INTOLERANCES" => "textarea",
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"Have you ever had any issues with local anesthesia?" => ["radio" => ['yes', 'no']],
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"Do you have a latex allergy?" => ["radio" => ['yes', 'no']],
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"Do you have a latex allergy?" => "text",
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"Current hormone replacement? if yes what?" => "text",
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"Past hormone replacement therapy" => "text"
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],
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"MEDICATIONS" => [
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"CURRENT MEDICATIONS" => 'textarea'
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],
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"Family history" => [
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"Heart disease" => ["radio" => ['yes', 'no']],
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"Diabetes" => ["radio" => ['yes', 'no']],
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"Osteoporosis" => ["radio" => ['yes', 'no']],
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"Alzheimer’s/dementia" => ["radio" => ['yes', 'no']],
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"Breast cancer" => ["radio" => ['yes', 'no']],
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"Other" => "text"
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],
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"HEALTH ASSESSMENT SYMPTOMS" => [
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"Sweating (night sweats or excessive sweating)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Sleep problems (difficulty falling asleep, sleeping through the night or waking up too early)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Increased need for sleep or falls asleep easily after a meal" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Depressive mood (feeling down, sad, lack of drive)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Irritability (mood swings, feeling aggressive, angers easily)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Anxiety (inner restlessness, feeling panicked, feeling nervous, inner tension)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Physical exhaustion (general decrease in muscle strength or endurance, decrease in work performance, fatigue, lack of energy, stamina or motivation)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Sexual problems (change in sexual desire or in sexual performance)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Bladder problems (difficulty in urinating, increased need to urinate)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Erectile changes (weaker erections, loss of morning erections)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Joint and muscular symptoms (joint pain or swelling, muscle weakness, poor recovery after exercise)" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Difficulties with memory" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Problems with thinking, concentrating or reasoning" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Difficulty learning new things" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Trouble thinking of the right word to describe persons, places or things when speaking" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Increase in frequency or intensity of headaches/migraines" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Rapid hair loss or thinning" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Feel cold all the time or have cold hands or feet" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Weight gain, increased belly fat, or difficulty losing weight despite diet and exercise" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Infrequent or absent ejaculations" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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"Difficulties with memory" => ["radio" => ['none', 'mild', 'moderate', 'severe', 'very severe']],
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]
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];
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