\r\n \r\n
\r\n {{ $t(\"BirthDay\") }}\r\n \r\n \r\n {{ $t(\"Gender\") }}\r\n ID.ID\"\r\n />\r\n
\r\n\r\n \r\n
\r\n {{ $t(\"MaritalStatus\") }}\r\n\r\n {{ $t(\"Single\") }}\r\n {{ $t(\"Married\") }}\r\n {{ $t(\"Divorced\") }}\r\n {{ $t(\"Widowed\") }}\r\n
\r\n\r\n \r\n
\r\n
{{ $t(\"HaveChildren\") }}\r\n
{{ $t(\"yes\") }}\r\n
{{ $t(\"no\") }}\r\n\r\n
{{ $t(\"Ifyeshowmany\") }}:
\r\n\r\n
\r\n\r\n
{{ $t(\"Age\") }}:
\r\n
\r\n
\r\n\r\n \r\n
\r\n
{{ $t(\"Internationalinsurance\") }}\r\n\r\n
{{ $t(\"yes\") }}\r\n
{{ $t(\"no\") }}\r\n\r\n
{{ $t(\"Insurancecompanyname\") }}
\r\n
\r\n \r\n \r\n \r\n\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Areyouasmoker\") }}
\r\n
{{ $t(\"yes\") }}\r\n
{{ $t(\"no\") }}\r\n
\r\n
{{ $t(\"Level\") }}:
\r\n
\r\n {{ $t(\"Heavy\") }}\r\n {{ $t(\"Moderate\") }}\r\n {{ $t(\"Occasionaly\") }}\r\n
\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Clarificationofeachcriteria6cigarettesadayconsideredasmoderate\") }}\r\n
\r\n \r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Doyoudrinkalcohol\") }}
\r\n
{{ $t(\"Yescurrently\") }}\r\n
{{ $t(\"Yesbutoccasionallyrarely\") }}\r\n
{{ $t(\"no\") }}\r\n
\r\n\r\n \r\n
\r\n
{{ $t(\"Howmanydrinksperday\") }}:
\r\n\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Areyoudiagnosedwithloworhighpressure\") }}
\r\n \r\n
{{ $t(\"Highpressure\") }}\r\n
\r\n
{{ $t(\"Lowpressure\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Areyouasthmatic\") }}
\r\n \r\n
{{ $t(\"yes\") }}\r\n
{{ $t(\"no\") }}\r\n
{{ $t(\"Ifyesdescripe\") }}:
\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Anycancerdiagnosishistoryinyourfamily\") }}
\r\n
{{ $t(\"yes\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
{{ $t(\"Ifyesdescripe\") }}:
\r\n
\r\n \r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"HaveDisease\") }}
\r\n
{{ $t(\"yes\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
{{ $t(\"Ifyesdescripe\") }}:
\r\n
\r\n \r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"HaveAids\") }}
\r\n
{{ $t(\"yes\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
{{ $t(\"Ifyeswhen\") }}:
\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"HaveHeartProblem\") }}
\r\n
{{ $t(\"yes\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"LastBloodAnalysis\") }}
\r\n\r\n
\r\n
\r\n\r\n \r\n
\r\n
\r\n {{ $t(\"Allergies\") }}
\r\n\r\n
\r\n \r\n
\r\n\r\n \r\n
\r\n
\r\n \r\n
\r\n {{ $t(\"Haveyougonethroughanysurgerybefore\") }}
\r\n
{{ $t(\"yes\") }}\r\n\r\n
{{ $t(\"no\") }}\r\n
\r\n \r\n \r\n \r\n \r\n \r\n
\r\n\r\n 0\r\n \"\r\n >\r\n
\r\n
\r\n
\r\n {{ item.SurgeryName }}\r\n
\r\n \r\n \r\n \r\n \r\n
\r\n
\r\n \r\n\r\n
\r\n \r\n {{ $t(\"Medication\") }}
\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n
\r\n\r\n 0\r\n \"\r\n >\r\n
\r\n
\r\n
\r\n {{ item.MedicineName }}\r\n
\r\n \r\n {{ item.Dose }}\r\n
\r\n \r\n {{ item.DurationInDay }}\r\n
\r\n \r\n \r\n \r\n \r\n
\r\n
\r\n \r\n
\r\n