|
Reporting Unit: {{ result.unit_lname }}
Entered By: {{ result.staff_name }}
On: {{ result.time_insert.strftime('%Y-%m-%d') }}
Record ID: {{ result.rec_id }}
|
|
| Identifying Data |
|
| Client Name: {{ client.fname }} {{ client.lname }} |
DOB: {{ client.dob }} |
Alias(es): {{ result.alias }} |
Allergies: {{ result.allergy }} |
|
| Address: {{ result.address }} | Apartment: {{ result.apartment }} |
City: {{ result.city }} | State: {{ result.state }} |
| Postal Code: {{ result.post_code }} |
Phone: {{ result.phone }} | Mobile Phone: {{ result.phone_mobile }} |
Other Phone: {{ result.phone_other }} |
|
| Sex Assigned At Birth: {{ result.sex_birth }} |
Gender Identity: {{ result.sex_gender }} |
Sexual Orientation: {{ result.sex_orientation }} |
|
| Race: {{ result.race }} |
If African-American: {{ result.race_detail }} |
| If Asian: {{ result.asian_detail }} |
| | If Pacific Islander: {{ result.pacific_detail }} |
|
| Ethnicity: {{ result.ethnicity }} |
If Hispanic/Latino: {{ result.ethnicity_detail }} |
| Place of Birth: {{ result.place_of_birth }} |
Preferred Language: {{ result.language_spoken }} |
Religion: {{ result.religion }} |
| US Citizen: {{ result.citizen }} |
US Veteran: {{ result.veteran }} |
|
| Marital Status: {{ result.marital_status }} |
Parental Status: {{ result.parental_status }} |
Household Composition: {{ result.household }} |
|
{% endfor %}