INSERT INTO `form_elements` VALUES
(1131,4,78,35,NULL,'radio','Natural or artificial (tanning bed and/or self-tanner) sun exposure in the past 3–4 weeks pre-treatment',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,1,0.00,NULL,NULL,NULL,1131),
(1132,4,78,35,NULL,'radio','Photosensitive herbal preparations (St John’s Wort, Ginkgo Biloba, etc…) or aromatherapy (essential oils)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,2,0.00,NULL,NULL,NULL,1132),
(1133,4,78,35,NULL,'radio','Concurrent or chronic skin disorders or lesions in the treatment area',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,3,0.00,NULL,NULL,NULL,1133),
(1134,4,78,35,1131,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,1,0.00,NULL,NULL,NULL,1134),
(1135,4,78,35,1132,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,2,0.00,NULL,NULL,NULL,1135),
(1136,4,78,35,1133,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,3,0.00,NULL,NULL,NULL,1136),
(1137,4,78,35,NULL,'radio','Inflammatory skin conditions (dermatitis, active acne, etc...)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,4,0.00,NULL,NULL,NULL,1137),
(1138,4,78,35,NULL,'radio','Actively receiving cancer treatments (on chemotherapy or radiation)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,5,0.00,NULL,NULL,NULL,1138),
(1139,4,78,35,NULL,'radio','History of cancer or pre-cancerous lesions in the treatment area (face and cheeks)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,6,0.00,NULL,NULL,NULL,1139),
(1140,4,78,35,NULL,'radio','Intake of tretinoin within the past year?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,7,0.00,NULL,NULL,NULL,1140),
(1141,4,78,35,NULL,'radio','Intake of Accutane within the past year?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,8,0.00,NULL,NULL,NULL,1141),
(1142,4,78,35,NULL,'radio','Medical history of Koebnerizing Isomorphic Diseases (vitiligo, psoriasis)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,9,0.00,NULL,NULL,NULL,1142),
(1143,4,78,35,NULL,'radio','Heal poorly and have a medical history of keloid scars?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,10,0.00,NULL,NULL,NULL,1143),
(1144,4,78,35,1137,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,4,0.00,NULL,NULL,NULL,1144),
(1145,4,78,35,1138,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,5,0.00,NULL,NULL,NULL,1145),
(1146,4,78,35,1139,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,6,0.00,NULL,NULL,NULL,1146),
(1147,4,78,35,1140,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,7,0.00,NULL,NULL,NULL,1147),
(1148,4,78,35,1141,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,8,0.00,NULL,NULL,NULL,1148),
(1149,4,78,35,1142,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,9,0.00,NULL,NULL,NULL,1149),
(1150,4,78,35,1143,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,10,0.00,NULL,NULL,NULL,1150),
(1151,4,78,35,NULL,'radio','Any tattoo and/or pigmented lesion on the treatment area that should be protected?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,11,0.00,NULL,NULL,NULL,1151),
(1152,4,78,35,NULL,'radio','Previous hair removal procedures on requested treatment area (other IPL/laser, wax, electrolysis, etc…)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,12,0.00,NULL,NULL,NULL,1152),
(1153,4,78,35,NULL,'radio','Any hair on requested treatment area that should not be removed?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,13,0.00,NULL,NULL,NULL,1153),
(1154,4,78,35,NULL,'radio','Botulinum Toxin within the treatment area within the past 2 weeks?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,14,0.00,NULL,NULL,NULL,1154),
(1155,4,78,35,NULL,'radio','Fillers, collagen, fat injections, threads or other injected bio-material in the treatment area within the past 4 weeks?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,15,0.00,NULL,NULL,NULL,1155),
(1156,4,78,35,NULL,'radio','Active skin or muscle inflammation, incomplete healing in treatment area post other procedures such as surgery, laser treatments, chemical peels, etc.',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,16,0.00,NULL,NULL,NULL,1156),
(1157,4,78,36,NULL,'radio','Intake of aspirin or anti-coagulants?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,17,0.00,NULL,NULL,NULL,1157),
(1158,4,78,36,NULL,'radio','Easy bruising?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,18,0.00,NULL,NULL,NULL,1158),
(1159,4,78,36,NULL,'radio','Severe bleeding or vascular disorders?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,19,0.00,NULL,NULL,NULL,1159),
(1160,4,78,36,NULL,'radio','Swollen legs or pain after long standing/sitting?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,20,0.00,NULL,NULL,NULL,1160),
(1161,4,78,36,NULL,'radio','Use of non-steroidal anti-inflammatory drugs within one week prior to treatment?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,21,0.00,NULL,NULL,NULL,1161),
(1162,4,78,36,NULL,'radio','Taking medicines that increase skin sensitivity to heat',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,22,0.00,NULL,NULL,NULL,1162),
(1163,4,78,36,NULL,'radio','Taking medicines that change skin metabolism',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,23,0.00,NULL,NULL,NULL,1163),
(1164,4,78,35,NULL,'radio','Presence or history of herpes simplex virus?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,24,0.00,NULL,NULL,NULL,1164),
(1165,4,78,35,NULL,'radio','Active cold sores, open lacerations or abrasions',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,25,0.00,NULL,NULL,NULL,1165),
(1166,4,78,36,NULL,'radio','Active local or systemic infections (cutaneous viral, fungal or bacterial diseases…)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,26,0.00,NULL,NULL,NULL,1166),
(1167,4,78,36,NULL,'radio','Hormonal or endocrine disorders (PCOS or uncontrolled diabetes?)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,27,0.00,NULL,NULL,NULL,1167),
(1168,4,78,36,NULL,'radio','Impaired immune system, immunosuppressive diseases or use of immunosuppressive medications (Systemic Lupus Erythematosus, Porphyria, HIV…)',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,28,0.00,NULL,NULL,NULL,1168),
(1182,4,78,35,1151,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,29,0.00,NULL,NULL,NULL,1169),
(1183,4,78,35,1152,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,30,0.00,NULL,NULL,NULL,1170),
(1184,4,78,35,1153,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,31,0.00,NULL,NULL,NULL,1171),
(1185,4,78,36,1154,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,32,0.00,NULL,NULL,NULL,1172),
(1186,4,78,36,1155,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,33,0.00,NULL,NULL,NULL,1173),
(1187,4,78,36,1156,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,34,0.00,NULL,NULL,NULL,1174),
(1188,4,78,36,1157,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,35,0.00,NULL,NULL,NULL,1175),
(1189,4,78,36,1158,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,36,0.00,NULL,NULL,NULL,1176),
(1190,4,78,36,1159,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,37,0.00,NULL,NULL,NULL,1177),
(1191,4,78,36,1160,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,38,0.00,NULL,NULL,NULL,1178),
(1192,4,78,36,1161,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,39,0.00,NULL,NULL,NULL,1179),
(1193,4,78,36,1162,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,40,0.00,NULL,NULL,NULL,1180),
(1194,4,78,36,1163,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,41,0.00,NULL,NULL,NULL,1181),
(1195,4,78,37,1164,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,42,0.00,NULL,NULL,NULL,1182),
(1196,4,78,36,1165,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,43,0.00,NULL,NULL,NULL,1183),
(1197,4,78,36,1166,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,44,0.00,NULL,NULL,NULL,1184),
(1198,4,78,36,1167,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,45,0.00,NULL,NULL,NULL,1185),
(1199,4,78,36,1168,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,46,0.00,NULL,NULL,NULL,1186),
(1200,4,78,36,NULL,'radio','Pacemaker, defibrillator, or any implanted electronic device',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,47,0.00,NULL,NULL,NULL,1187),
(1201,4,78,36,NULL,'radio','Do you have any metal implants anywhere in your body?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,48,0.00,NULL,NULL,NULL,1188),
(1202,4,78,36,NULL,'radio','Any known allergies?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,49,0.00,NULL,NULL,NULL,1189),
(1203,4,78,36,NULL,'radio','Any disease in which a temperature increase is contraindicated?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,50,0.00,NULL,NULL,NULL,1190),
(1204,4,78,36,NULL,'radio','Cannot feel heat because of nerve damage?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,51,0.00,NULL,NULL,NULL,1191),
(1205,4,78,36,NULL,'radio','Suspected or diagnosed heart problems?',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,52,0.00,NULL,NULL,NULL,1192),
(1206,4,78,36,NULL,'radio','Suspected or diagnosed epilepsy or uncontrolled seizure disorders',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,53,0.00,NULL,NULL,NULL,1193),
(1207,4,78,36,NULL,'radio','Pregnant or possibility of pregnancy, postpartum or nursing',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,54,0.00,NULL,NULL,NULL,1194),
(1208,4,78,37,NULL,'radio','I voluntarily provide full consent to Carolina Eye Doctors to capture photographs and/or video recordings of me for the purpose of showcasing realistic before-and-after results. I understand that these images may be used for awareness, education, and marketing purposes in materials such as the website, print media, and event documentation. I acknowledge that the images may be edited and published online or in print without further notification.',NULL,'[{\"label\": \"Yes\", \"value\": \"Yes\"}, {\"label\": \"No\", \"value\": \"No\"}]','Yes',NULL,1,55,0.00,NULL,NULL,NULL,1195),
(1215,4,78,36,1200,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,56,0.00,NULL,NULL,NULL,1196),
(1216,4,78,36,1201,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,57,0.00,NULL,NULL,NULL,1197),
(1217,4,78,36,1202,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,58,0.00,NULL,NULL,NULL,1198),
(1218,4,78,36,1203,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,59,0.00,NULL,NULL,NULL,1199),
(1219,4,78,36,1204,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,60,0.00,NULL,NULL,NULL,1200),
(1220,4,78,36,1205,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,61,0.00,NULL,NULL,NULL,1201),
(1221,4,78,36,1206,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,62,0.00,NULL,NULL,NULL,1202),
(1222,4,78,36,1207,'textarea','Please provide detail',NULL,NULL,NULL,NULL,0,63,0.00,NULL,NULL,NULL,1203),
(1223,4,78,37,NULL,'signature','Patient Signature','Any \"YES\" response in the form above will be assessed by the Physician or Esthetician, who will determine treatment eligibility and any necessary precautions, as additional caution may be required for the procedure. All concerns will be reviewed and questions fully addressed before beginning treatment.\n<br><br>\nIf any changes in your health or medical status occur, you must disclose them to ensure your safety. This allows the treatment plan to be adjusted as needed or discontinued if necessary.\n<br><br>\nI confirm that I have fully and honestly disclosed all relevant medical history, medications, allergies, and recent treatments to my provider. I understand that providing false, incomplete, or inaccurate information may increase the risk of adverse effects and impact the safety and effectiveness of my treatment. I have read and understood this informed consent form and completed it to the best of my ability.\n',NULL,NULL,NULL,1,98,0.00,NULL,NULL,NULL,1207),
(1224,4,78,37,NULL,'signature','Doctor Signature','Please sign below to confirm you have reviewed the patient information',NULL,NULL,NULL,1,99,0.00,NULL,NULL,NULL,1208),
(1225,4,78,36,NULL,'textarea','List of additional current medication/ supplements taken',NULL,NULL,NULL,NULL,0,64,0.00,NULL,NULL,NULL,1206),
(1228,4,74,38,NULL,'email','Patient Email',NULL,NULL,NULL,NULL,0,1,0.00,NULL,0,5,1119),
(1229,4,74,38,NULL,'input','First Name',NULL,NULL,NULL,NULL,0,2,0.00,NULL,NULL,NULL,1120);
