\n ';
};
var getNav = function getNav() {
var _state8 = state,
availableDays = _state8.availableDays,
dateStr = _state8.date;
var next = void 0;
var prev = void 0;
var _dateStr$split2 = dateStr.split('-'),
year = _dateStr$split2[0],
month = _dateStr$split2[1];
if (availableDays) {
var dayIndex = availableDays.indexOf(dateStr);
if (dayIndex > 0) {
prev = availableDays[dayIndex - 1];
} else {
var prevDate = new Date(year, month - 1, 0);
prev = toDateStr(prevDate);
}
if (dayIndex + 1 \n \n \n
\n ';
};
var renderTimezonePicker = function renderTimezonePicker() {
var _state10 = state,
timezone = _state10.timezone,
timezones = _state10.timezones;
return '\n
\n \n
' + timezone + '
\n
\n ';
};
var renderCalendarDays = function renderCalendarDays() {
var _state11 = state,
slots = _state11.slots,
dateStr = _state11.date,
value = _state11.value,
availableDays = _state11.availableDays;
var days = slots ? Object.keys(slots) : [];
var todayStr = toDateStr(new Date());
if (!days.length) {
return '';
}
var firstDay = getDay(new Date(days[0]));
days.unshift.apply(days, fillArray(new Array(firstDay), 'precedingDay'));
var trailingDays = Math.ceil(days.length / 7) * 7 - days.length;
days.push.apply(days, fillArray(new Array(trailingDays), 'trailingDay'));
var weeks = days.map(function (item, i) {
return i % 7 === 0 ? days.slice(i, i + 7) : null;
}).filter(function (a) {
return a;
});
var dateValue = value && value.split(' ')[0];
return '\n ' + weeks.map(function (week) {
return '
' + week.map(function (day) {
if (day === 'precedingDay' || day === 'trailingDay') {
return '';
}
var active = day === dateStr;
var isToday = todayStr === day;
var isUnavailable = availableDays.indexOf(day) === -1;
var isSelected = day === dateValue;
var classes = 'calendarDay ' + classNames({
isSelected: isSelected,
isToday: isToday,
isUnavailable: isUnavailable,
isActive: active
});
return '
' + day.split('-')[2].replace(/^0/, '') + '
';
}).join('') + '
';
}).join('') + '\n ';
};
var renderEmptyState = function renderEmptyState() {
/* eslint-disable */
return '\n
\n
\n
\n \n
\n
' + JotForm.texts.noSlotsAvailable + '
\n
\n
\n ';
/* eslint-enable */
};
var dateWithAMPM = function dateWithAMPM() {
var date = arguments.length > 0 && arguments[0] !== undefined ? arguments[0] : '';
var _props6 = props,
_props6$timeFormat = _props6.timeFormat;
_props6$timeFormat = _props6$timeFormat === undefined ? {} : _props6$timeFormat;
var _props6$timeFormat$va = _props6$timeFormat.value,
timeFormat = _props6$timeFormat$va === undefined ? '24 Hour' : _props6$timeFormat$va;
var time = new Date(date.replace(/-/g, '/')).toLocaleTimeString('en-US', { hour: 'numeric', minute: 'numeric', hourCycle: timeFormat === 'AM/PM' ? 'h12' : 'h23' });
var day = date && date.split(' ')[0];
return day + ' ' + time;
};
var renderSlots = function renderSlots() {
var _state12 = state,
dateStr = _state12.date,
_state12$value = _state12.value,
dateValue = _state12$value === undefined ? '' : _state12$value,
_state12$defaultValue = _state12.defaultValue,
defaultValue = _state12$defaultValue === undefined ? '' : _state12$defaultValue,
defaultTimezone = _state12.defaultTimezone,
timezone = _state12.timezone;
var dateSlots = state.slots && state.slots[dateStr] || {};
var stateValue = dateWithAMPM(dateValue);
var defaultValueTZ = revertDate(defaultValue, defaultTimezone, timezone);
var parsedDefaultVal = dateWithAMPM(defaultValueTZ);
var entries = objectEntries(dateSlots);
if (!entries || !entries.length) {
return renderEmptyState();
}
return entries.map(function (_ref5) {
var name = _ref5[0],
value = _ref5[1];
var rn = amPmConverter(name);
var slotValue = dateStr + ' ' + rn;
var active = stateValue === slotValue;
var disabled = !(value || parsedDefaultVal === slotValue);
return '
' + name + '
';
}).join('');
};
var renderDay = function renderDay() {
var _state13 = state,
dateStr = _state13.date;
var date = new Date(dateStr);
var day = getDay(date);
return '\n
\n ';
afterRender();
});
var update = function update(newProps) {
state = assignObject({}, state, getStateFromProps(newProps));
props = newProps;
load();
};
input.addEventListener('change', function (e) {
var date = toDateTimeStr(dz(new Date(e.target.value), -5, getTimezoneOffset(state.timezone)));
setDate(date.split(' ')[0]);
setState({ value: date, defaultValue: date });
// validation(date);
});
tzInput.addEventListener('change', function (e) {
var defaultTimezone = e.target.value;
setTimezone(defaultTimezone);
setState({ defaultTimezone: defaultTimezone });
});
document.addEventListener('translationLoad', function () {
return render();
});
var getInitialData = function getInitialData(timezones) {
getFirstAvailableDates(function (data) {
JotForm.appointments.initialData = data;
JotForm.appointments.listeners.forEach(function (fn) {
return fn({ data: data, timezones: timezones });
});
});
};
if (!JotForm.appointments) {
JotForm.appointments = { listeners: [] };
loadTimezones(function (timezones) {
JotForm.timezones = timezones;
getInitialData(timezones);
});
}
var requestTry = 1;
var requestTimeout = 1000;
var construct = function construct(_ref6) {
var data = _ref6.data,
timezones = _ref6.timezones;
var qdata = data[props.id.value];
if (!qdata || qdata.error) {
constructed = true;
if (!qdata && requestTry -1;
});
if (!matchedTimezone) return false;
return group.group + '/' + matchedTimezone;
};
var timezone = setUpdatedTimezone(userTimezone) || setUpdatedTimezone(props.timezone.value) || props.timezone.value;
setTimezone(timezone);
var dateStr = Object.keys(qdata)[0];
var _getDateRange2 = getDateRange(dateStr),
startDate = _getDateRange2[0],
endDate = _getDateRange2[1];
updateMonthData(startDate, endDate, qdata);
var _state17 = state,
availableDays = _state17.availableDays;
var newDate = availableDays.indexOf(dateStr) === -1 ? availableDays[0] : dateStr;
constructed = true;
setState({
timezones: timezones,
loading: false,
date: newDate || dateStr
});
};
JotForm.appointments.listeners.push(construct);
if (JotForm.appointments.initialData) {
setTimeout(function () {
construct({
data: JotForm.appointments.initialData,
timezones: JotForm.timezones
});
}, requestTimeout);
}
return update;
})({"text":{"text":"Question","value":"Your Preferred Appointment Date/Time"},"labelAlign":{"text":"Label Align","value":"Top","dropdown":[["Auto","Auto"],["Left","Left"],["Right","Right"],["Top","Top"]]},"required":{"text":"Required","value":"No","dropdown":[["No","No"],["Yes","Yes"]]},"description":{"text":"Hover Text","value":"","textarea":true},"slotDuration":{"text":"Slot Duration","value":"45","dropdown":[[15,"15 min"],[30,"30 min"],[45,"45 min"],[60,"60 min"],["custom","Custom min"]],"hint":"Select how long each slot will be."},"startDate":{"text":"Start Date","value":""},"endDate":{"text":"End Date","value":""},"intervals":{"text":"Intervals","value":[{"from":"09:00","to":"17:00","days":["Mon","Tue","Wed","Thu","Fri"]}],"hint":"The hours will be applied to the selected days and repeated."},"useBlockout":{"text":"Blockout Custom Dates","value":"No","dropdown":[["No","No"],["Yes","Yes"]],"hint":"Disable certain date(s) in the calendar."},"blockoutDates":{"text":"Blockout dates","value":[{"startDate":"","endDate":""}]},"useLunchBreak":{"text":"Lunch Time","value":"Yes","dropdown":[["No","No"],["Yes","Yes"]],"hint":"Enable lunchtime in the calendar."},"lunchBreak":{"text":"Lunchtime hours","value":[{"from":"12:00","to":"14:00"}]},"timezone":{"text":"Timezone","value":"America/Los_Angeles (GMT-08:00)"},"timeFormat":{"text":"Time Format","value":"AM/PM","dropdown":[["24 Hour","24 Hour"],["AM/PM","AM/PM"]],"icon":"images/blank.gif","iconClassName":"toolbar-time_format_24"},"months":{"value":["January","February","March","April","May","June","July","August","September","October","November","December"],"hidden":true},"days":{"value":["Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"],"hidden":true},"startWeekOn":{"text":"Start Week On","value":"Sunday","dropdown":[["Monday","Monday"],["Sunday","Sunday"]],"toolbar":false},"rollingDays":{"text":"Rolling Days","value":"60","toolbar":false},"appointmentType":{"hidden":true,"value":"single"},"dateFormat":{"hidden":true,"value":"mm/dd/yyyy"},"maxAttendee":{"hidden":true,"value":"5"},"maxEvents":{"hidden":true,"value":"5"},"minScheduleNotice":{"hidden":true,"value":"120"},"name":{"hidden":true,"value":"yourPreferred"},"order":{"hidden":true,"value":"52"},"protected":{"hidden":true,"value":"Yes"},"qid":{"toolbar":false,"value":"input_57"},"type":{"hidden":true,"value":"control_appointment"},"id":{"toolbar":false,"value":"57"},"qname":{"toolbar":false,"value":"q57_yourPreferred"},"cdnconfig":{"CDN":"https://cdn.jotfor.ms/"},"passive":false,"formProperties":{"products":false,"highlightLine":"Enabled","coupons":false,"useStripeCoupons":false,"taxes":false,"comparePaymentForm":"","paymentListSettings":false,"newPaymentUIForNewCreatedForms":false,"formBackground":"#fff"},"formID":210236467188055,"themeVersion":"v1"});
JotForm.newDefaultTheme = false;
JotForm.extendsNewTheme = false;
JotForm.newPaymentUIForNewCreatedForms = false;
JotForm.hipaa = true;
JotForm.alterTexts(undefined);
JotForm.clearFieldOnHide="disable";
setTimeout(function() {
JotForm.initMultipleUploads();
}, 2);
JotForm.submitError="jumpToFirstError";
/*INIT-END*/
});
JotForm.prepareCalculationsOnTheFly([null,{"name":"pastMedical","qid":"1","text":"Past Medical History Form","type":"control_head"},null,{"name":"personalInformation","qid":"3","text":"Personal Information","type":"control_head"},{"description":"","name":"name","qid":"4","text":"Name","type":"control_fullname"},{"description":"","name":"birthDate","qid":"5","text":"Birth Date","type":"control_birthdate"},{"description":"","name":"gender","qid":"6","text":"Gender","type":"control_radio"},{"name":"divider","qid":"7","type":"control_divider"},null,{"description":"Enter your phone number, prefer cell phone number so that you can receive text messages. ","name":"phoneNumber","qid":"9","text":"Phone Number","type":"control_phone"},null,{"name":"divider11","qid":"11","type":"control_divider"},{"description":"Please enter the name of your health insurance","name":"healthInsurance12","qid":"12","subLabel":"Name of your active health insurance","text":"Health Insurance provider","type":"control_textbox"},{"name":"bodyMeasurement","qid":"13","text":"Body Measurement","type":"control_widget"},null,{"description":"Your Dominant Hand ?","name":"handedness","qid":"15","subLabel":"Your Dominant Hand","text":"Handedness","type":"control_dropdown"},{"name":"divider16","qid":"16","type":"control_divider"},{"description":"","name":"emergencyContact","qid":"17","text":"Emergency Contact Name","type":"control_fullname"},{"description":"","name":"relationship","qid":"18","subLabel":"","text":"Relationship","type":"control_textbox"},null,{"description":"","name":"emergencyContact20","qid":"20","text":"Emergency Contact Phone Number","type":"control_phone"},{"name":"divider21","qid":"21","type":"control_divider"},{"description":"","name":"referredBy","qid":"22","text":"Referred By","type":"control_fullname"},null,{"description":"","name":"primaryCare24","qid":"24","subLabel":"Your PCP Name","text":"Primary Care Physician Name","type":"control_email"},{"name":"pageBreak","qid":"25","text":"Page Break","type":"control_pagebreak"},{"name":"healthInformation","qid":"26","text":"Health Information","type":"control_head"},{"name":"pleaseIndicate","qid":"27","text":"Please indicate your allergies","type":"control_widget"},{"name":"pastMedical28","qid":"28","text":"Past Medical History","type":"control_widget"},{"name":"pleaseList29","qid":"29","text":"Please list any past surgeries with date","type":"control_widget"},{"name":"pleaseList30","qid":"30","text":"Please list your Current Medications\u002FDose\u002Ffrequency","type":"control_widget"},{"name":"pageBreak31","qid":"31","text":"Page Break","type":"control_pagebreak"},{"name":"socialHistory","qid":"32","text":"Social History","type":"control_head"},null,{"description":"","name":"socialHabits","qid":"34","text":"Social Habits","type":"control_checkbox"},{"description":"","name":"sleepingPattern","qid":"35","text":"Sleeping pattern","type":"control_checkbox"},null,null,null,{"description":"","name":"furtherCommentsinformation","qid":"39","subLabel":"If you want to add more health information","text":"Further comments\u002Finformation","type":"control_textarea"},{"name":"pageBreak40","qid":"40","text":"Page Break","type":"control_pagebreak"},null,null,null,null,{"name":"familyMedical","qid":"45","text":"Family Medical History","type":"control_head"},null,{"name":"hasAnyone47","qid":"47","text":"Has anyone in your family had a psychiatric illness?","type":"control_widget"},{"name":"hasAnyone48","qid":"48","text":"Has anyone in your family have a genetic disease?","type":"control_widget"},{"description":"","name":"pleaseIndicate49","qid":"49","subLabel":"","text":"Please indicate further details if yes","type":"control_textarea"},{"name":"pageBreak50","qid":"50","text":"Page Break","type":"control_pagebreak"},null,{"description":"","name":"date","qid":"52","text":"Date","type":"control_datetime"},null,{"name":"submit","qid":"54","text":"Submit","type":"control_button"},{"name":"uploadA","qid":"55","text":"Upload a picture of front page of your insurance card","type":"control_widget"},{"name":"uploadA56","qid":"56","text":"Upload a picture of back page of your insurance card","type":"control_widget"},{"description":"","name":"yourPreferred","qid":"57","text":"Your Preferred Appointment Date\u002FTime","type":"control_appointment"},{"description":"","name":"reasonFor","qid":"58","subLabel":"","text":"Reason for neurology visit","type":"control_textbox"},null,{"name":"hasAnyone60","qid":"60","text":"Has anyone in your family have a Neurological disease?","type":"control_widget"},{"name":"hasAnyone","qid":"61","text":"Has anyone in your family have a Heart disease?","type":"control_widget"},{"name":"hasAnyone62","qid":"62","text":"Has anyone in your family have a Bleeding disorder?","type":"control_widget"},{"name":"hasAnyone63","qid":"63","text":"Has anyone in your family have a Aneurysmal disease?","type":"control_widget"},null,{"description":"","name":"ifYou65","qid":"65","subLabel":"Any past records\u002F testing such as MRI, CT scan, EMG\u002FNerve conduction studies","text":"If you want to upload any files\u002FPDF for the Physician to know","type":"control_fileupload"},null,null,null,null,null,{"name":"takeA71","qid":"71","text":"Take a picture of front of your insurance card (if you didn't upload above)","type":"control_widget"},{"name":"takeA","qid":"72","text":"Take a picture of back of your insurance card (if you didn't upload above)","type":"control_widget"},{"name":"typeA73","qid":"73","text":"Terms and Conditions","type":"control_widget"},{"name":"typeA74","qid":"74","text":"Signature","type":"control_widget"},null,{"name":"uniqueId","qid":"76","text":"Unique ID","type":"control_autoincrement"},null,{"name":"typeA78","qid":"78","text":"","type":"control_widget"},{"name":"yourEmail","qid":"79","text":"Your Email address: ","type":"control_widget"},null,null,null,null,null,null,null,null,{"name":"consent","qid":"88","text":"Consent ","type":"control_head"},{"description":"","name":"address89","qid":"89","text":"Address","type":"control_address"}]);
setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,{"name":"pastMedical","qid":"1","text":"Past Medical History Form","type":"control_head"},null,{"name":"personalInformation","qid":"3","text":"Personal Information","type":"control_head"},{"description":"","name":"name","qid":"4","text":"Name","type":"control_fullname"},{"description":"","name":"birthDate","qid":"5","text":"Birth Date","type":"control_birthdate"},{"description":"","name":"gender","qid":"6","text":"Gender","type":"control_radio"},{"name":"divider","qid":"7","type":"control_divider"},null,{"description":"Enter your phone number, prefer cell phone number so that you can receive text messages. ","name":"phoneNumber","qid":"9","text":"Phone Number","type":"control_phone"},null,{"name":"divider11","qid":"11","type":"control_divider"},{"description":"Please enter the name of your health insurance","name":"healthInsurance12","qid":"12","subLabel":"Name of your active health insurance","text":"Health Insurance provider","type":"control_textbox"},{"name":"bodyMeasurement","qid":"13","text":"Body Measurement","type":"control_widget"},null,{"description":"Your Dominant Hand ?","name":"handedness","qid":"15","subLabel":"Your Dominant Hand","text":"Handedness","type":"control_dropdown"},{"name":"divider16","qid":"16","type":"control_divider"},{"description":"","name":"emergencyContact","qid":"17","text":"Emergency Contact Name","type":"control_fullname"},{"description":"","name":"relationship","qid":"18","subLabel":"","text":"Relationship","type":"control_textbox"},null,{"description":"","name":"emergencyContact20","qid":"20","text":"Emergency Contact Phone Number","type":"control_phone"},{"name":"divider21","qid":"21","type":"control_divider"},{"description":"","name":"referredBy","qid":"22","text":"Referred By","type":"control_fullname"},null,{"description":"","name":"primaryCare24","qid":"24","subLabel":"Your PCP Name","text":"Primary Care Physician Name","type":"control_email"},{"name":"pageBreak","qid":"25","text":"Page Break","type":"control_pagebreak"},{"name":"healthInformation","qid":"26","text":"Health Information","type":"control_head"},{"name":"pleaseIndicate","qid":"27","text":"Please indicate your allergies","type":"control_widget"},{"name":"pastMedical28","qid":"28","text":"Past Medical History","type":"control_widget"},{"name":"pleaseList29","qid":"29","text":"Please list any past surgeries with date","type":"control_widget"},{"name":"pleaseList30","qid":"30","text":"Please list your Current Medications\u002FDose\u002Ffrequency","type":"control_widget"},{"name":"pageBreak31","qid":"31","text":"Page Break","type":"control_pagebreak"},{"name":"socialHistory","qid":"32","text":"Social History","type":"control_head"},null,{"description":"","name":"socialHabits","qid":"34","text":"Social Habits","type":"control_checkbox"},{"description":"","name":"sleepingPattern","qid":"35","text":"Sleeping pattern","type":"control_checkbox"},null,null,null,{"description":"","name":"furtherCommentsinformation","qid":"39","subLabel":"If you want to add more health information","text":"Further comments\u002Finformation","type":"control_textarea"},{"name":"pageBreak40","qid":"40","text":"Page Break","type":"control_pagebreak"},null,null,null,null,{"name":"familyMedical","qid":"45","text":"Family Medical History","type":"control_head"},null,{"name":"hasAnyone47","qid":"47","text":"Has anyone in your family had a psychiatric illness?","type":"control_widget"},{"name":"hasAnyone48","qid":"48","text":"Has anyone in your family have a genetic disease?","type":"control_widget"},{"description":"","name":"pleaseIndicate49","qid":"49","subLabel":"","text":"Please indicate further details if yes","type":"control_textarea"},{"name":"pageBreak50","qid":"50","text":"Page Break","type":"control_pagebreak"},null,{"description":"","name":"date","qid":"52","text":"Date","type":"control_datetime"},null,{"name":"submit","qid":"54","text":"Submit","type":"control_button"},{"name":"uploadA","qid":"55","text":"Upload a picture of front page of your insurance card","type":"control_widget"},{"name":"uploadA56","qid":"56","text":"Upload a picture of back page of your insurance card","type":"control_widget"},{"description":"","name":"yourPreferred","qid":"57","text":"Your Preferred Appointment Date\u002FTime","type":"control_appointment"},{"description":"","name":"reasonFor","qid":"58","subLabel":"","text":"Reason for neurology visit","type":"control_textbox"},null,{"name":"hasAnyone60","qid":"60","text":"Has anyone in your family have a Neurological disease?","type":"control_widget"},{"name":"hasAnyone","qid":"61","text":"Has anyone in your family have a Heart disease?","type":"control_widget"},{"name":"hasAnyone62","qid":"62","text":"Has anyone in your family have a Bleeding disorder?","type":"control_widget"},{"name":"hasAnyone63","qid":"63","text":"Has anyone in your family have a Aneurysmal disease?","type":"control_widget"},null,{"description":"","name":"ifYou65","qid":"65","subLabel":"Any past records\u002F testing such as MRI, CT scan, EMG\u002FNerve conduction studies","text":"If you want to upload any files\u002FPDF for the Physician to know","type":"control_fileupload"},null,null,null,null,null,{"name":"takeA71","qid":"71","text":"Take a picture of front of your insurance card (if you didn't upload above)","type":"control_widget"},{"name":"takeA","qid":"72","text":"Take a picture of back of your insurance card (if you didn't upload above)","type":"control_widget"},{"name":"typeA73","qid":"73","text":"Terms and Conditions","type":"control_widget"},{"name":"typeA74","qid":"74","text":"Signature","type":"control_widget"},null,{"name":"uniqueId","qid":"76","text":"Unique ID","type":"control_autoincrement"},null,{"name":"typeA78","qid":"78","text":"","type":"control_widget"},{"name":"yourEmail","qid":"79","text":"Your Email address: ","type":"control_widget"},null,null,null,null,null,null,null,null,{"name":"consent","qid":"88","text":"Consent ","type":"control_head"},{"description":"","name":"address89","qid":"89","text":"Address","type":"control_address"}]);}, 20);