Patient Information

What is the client’s first name?

What is the client’s last name?

Does the client have a former name the medical records may be under?

Choices: Yes / No

What is the client’s full former name?

What is the client’s date of birth?

What are the last four digits of the client’s Social Security Number?

What is the client’s street address?

City:

State:

Select box

Zip:

What is the client’s email address?

What is the client’s phone number?

Case Email

Information for developers

Source code for question

fields:
- What is the client's first name?: Client_First_Name
  datatype: text
  help: 'This comes from the "First Name" field in Legal Server.'
- What is the client's last name?: Client_Last_Name
  datatype: text
  help: 'This comes from the "Last Name" field in Legal Server.'
- Does the client have a former name the medical records may be under?: Client_Former_NameYN
  datatype: yesnoradio
- What is the client's full former name?: Client_Former_Name
  datatype: text
  show if:
    is: true
    variable: Client_Former_NameYN
- What is the client's date of birth?: Client_DOB
  datatype: date
- What are the last four digits of the client's Social Security Number?: Client_SSN
  datatype: text
- What is the client's street address?: Client_Address
  datatype: text
  help: 'This comes from the "Street Address" field in Legal Server.'
- 'City:': Client_Address_City
  datatype: text
  help: 'This comes from the "City" field in Legal Server.'
- 'State:': Client_Address_State
  choices:
  - AL: AL
  - AK: AK
  - AZ: AZ
  - AR: AR
  - CA: CA
  - CO: CO
  - CT: CT
  - DE: DE
  - FL: FL
  - GA: GA
  - HI: HI
  - ID: ID
  - IL: IL
  - IN: IN
  - IO: IO
  - KS: KS
  - KY: KY
  - LA: LA
  - ME: ME
  - MD: MD
  - MA: MA
  - MI: MI
  - MN: MN
  - MS: MS
  - MO: MO
  - MT: MT
  - NE: NE
  - NV: NV
  - NH: NH
  - NJ: NJ
  - NM: NM
  - NY: NY
  - NC: NC
  - ND: ND
  - OH: OH
  - OK: OK
  - OR: OR
  - PA: PA
  - RI: RI
  - SC: SC
  - SD: SD
  - TN: TN
  - TX: TX
  - UT: UT
  - VT: VT
  - VA: VA
  - WA: WA
  - WV: WV
  - WI: WI
  - WY: WY
  datatype: dropdown
  help: 'This comes from the "State" field in Legal Server.'
- 'Zip:': Client_Address_Zip
  datatype: text
  help: 'This comes from the "Zip Code" field in Legal Server.'
- What is the client's email address?: Client_Email
  datatype: text
  help: 'This comes from the "Email Address" field in Legal Server.'
- What is the client's phone number?: Client_Phone
  datatype: text
  help: 'This comes from the "Telephone Number" field in Legal Server.'
- Case Email: legalserver_case_email
  datatype: email
question: Patient Information
validation code: |-
  if not defined('Client_DOB') or not Client_DOB:
    Client_DOB = DAEmpty()
  if Client_Former_NameYN != True:
    Client_Former_Name = ''

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