"amyotrophic lateral sclerosis"[MeSH Terms] AND management

"amyotrophic lateral sclerosis"[MeSH Terms] AND "physical therapy"[MeSH Terms]

"amyotrophic lateral sclerosis" AND "exercise" AND rehabilitation

PMID: 38762656

PMID: 40273110

PMID: 41375893

PMID: 39182937

PMID: 40488544

PMID: 42038869

mkdir -p /home/daytona/workspace/als-intake-form && ls /home/daytona/workspace/a…

~/als-intake-form/generate_form.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  AlignmentType, HeadingLevel, BorderStyle, WidthType, ShadingType,
  VerticalAlign, PageNumber, Header, Footer, PageBreak,
  UnderlineType
} = require('docx');
const fs = require('fs');

// ─── Helpers ────────────────────────────────────────────────────────────────

const TEAL      = "1A7A8A";
const TEAL_LIGHT = "E6F4F6";
const GREY_LIGHT = "F5F5F5";
const WHITE      = "FFFFFF";
const DARK       = "1A1A2E";
const MID_GREY   = "CCCCCC";

function sectionHeader(text) {
  return new Paragraph({
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 280, after: 100 },
    shading: { type: ShadingType.SOLID, color: TEAL },
    children: [
      new TextRun({
        text: text,
        color: WHITE,
        bold: true,
        size: 24,
        font: "Calibri",
      }),
    ],
  });
}

function subHeader(text) {
  return new Paragraph({
    spacing: { before: 200, after: 60 },
    children: [
      new TextRun({
        text: text,
        bold: true,
        color: TEAL,
        size: 22,
        font: "Calibri",
        underline: { type: UnderlineType.SINGLE, color: TEAL },
      }),
    ],
  });
}

function label(text) {
  return new TextRun({ text, bold: true, size: 20, font: "Calibri", color: DARK });
}

function field(width = 3500) {
  return new TextRun({ text: "_".repeat(Math.floor(width / 80)), size: 20, font: "Calibri", color: MID_GREY });
}

function labelLine(labelText, extraField = "") {
  return new Paragraph({
    spacing: { before: 80, after: 60 },
    children: [
      label(labelText + "  "),
      field(),
      ...(extraField ? [new TextRun({ text: "    " }), label(extraField + "  "), field()] : []),
    ],
  });
}

function checkboxLine(labelText, options) {
  const runs = [label(labelText + ":  ")];
  options.forEach((opt) => {
    runs.push(new TextRun({ text: "\u25A1 " + opt + "   ", size: 20, font: "Calibri" }));
  });
  return new Paragraph({ spacing: { before: 80, after: 60 }, children: runs });
}

function yesNoLine(labelText) {
  return checkboxLine(labelText, ["Yes", "No"]);
}

function multiLine(labelText) {
  return [
    new Paragraph({
      spacing: { before: 80, after: 20 },
      children: [label(labelText)],
    }),
    new Paragraph({
      spacing: { before: 0, after: 40 },
      children: [new TextRun({ text: "_".repeat(120), size: 20, font: "Calibri", color: MID_GREY })],
    }),
    new Paragraph({
      spacing: { before: 0, after: 60 },
      children: [new TextRun({ text: "_".repeat(120), size: 20, font: "Calibri", color: MID_GREY })],
    }),
  ];
}

function smallNote(text) {
  return new Paragraph({
    spacing: { before: 40, after: 40 },
    children: [new TextRun({ text, size: 17, font: "Calibri", color: "888888", italics: true })],
  });
}

function spacer() {
  return new Paragraph({ spacing: { before: 60, after: 60 }, children: [new TextRun("")] });
}

// ─── Scoring Table ───────────────────────────────────────────────────────────

function scoreTable(title, rows) {
  const headerRow = new TableRow({
    tableHeader: true,
    children: ["Domain", "Score", "Notes"].map((h) =>
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL },
        children: [new Paragraph({
          children: [new TextRun({ text: h, bold: true, color: WHITE, size: 20, font: "Calibri" })],
          alignment: AlignmentType.CENTER,
        })],
        verticalAlign: VerticalAlign.CENTER,
      })
    ),
  });

  const dataRows = rows.map((r, i) =>
    new TableRow({
      children: [
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 40, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: r, size: 19, font: "Calibri" })] })],
        }),
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 20, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: "___/___", size: 19, font: "Calibri", color: MID_GREY })] })],
        }),
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 40, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: "________________________________", size: 19, font: "Calibri", color: MID_GREY })] })],
        }),
      ],
    })
  );

  return [
    subHeader(title),
    new Table({
      width: { size: 100, type: WidthType.PERCENTAGE },
      rows: [headerRow, ...dataRows],
    }),
    spacer(),
  ];
}

// ─── Two-column row helper ────────────────────────────────────────────────────

function twoColRow(left, right) {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top: { style: BorderStyle.NONE }, bottom: { style: BorderStyle.NONE },
      left: { style: BorderStyle.NONE }, right: { style: BorderStyle.NONE },
      insideH: { style: BorderStyle.NONE }, insideV: { style: BorderStyle.NONE },
    },
    rows: [
      new TableRow({
        children: [
          new TableCell({ width: { size: 50, type: WidthType.PERCENTAGE }, children: [left] }),
          new TableCell({ width: { size: 50, type: WidthType.PERCENTAGE }, children: [right] }),
        ],
      }),
    ],
  });
}

// ─── Muscle Strength Table ───────────────────────────────────────────────────

function muscleTable() {
  const muscles = [
    ["Shoulder Abductors", "", ""],
    ["Elbow Flexors", "", ""],
    ["Elbow Extensors", "", ""],
    ["Wrist Extensors", "", ""],
    ["Finger Flexors", "", ""],
    ["Intrinsic Hand / Thenar", "", ""],
    ["Hip Flexors", "", ""],
    ["Knee Extensors", "", ""],
    ["Knee Flexors", "", ""],
    ["Ankle Dorsiflexors", "", ""],
    ["Ankle Plantar Flexors", "", ""],
    ["Neck Flexors", "", ""],
    ["Neck Extensors", "", ""],
  ];

  const headerRow = new TableRow({
    tableHeader: true,
    children: ["Muscle Group", "R (MRC 0-5)", "L (MRC 0-5)", "Notes"].map((h) =>
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL },
        children: [new Paragraph({
          children: [new TextRun({ text: h, bold: true, color: WHITE, size: 19, font: "Calibri" })],
          alignment: AlignmentType.CENTER,
        })],
      })
    ),
  });

  const dataRows = muscles.map((m, i) =>
    new TableRow({
      children: [
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 40, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: m[0], size: 19, font: "Calibri" })] })],
        }),
        ...["R", "L", "Notes"].map(() =>
          new TableCell({
            shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
            width: { size: 20, type: WidthType.PERCENTAGE },
            children: [new Paragraph({ children: [new TextRun({ text: "________", size: 19, font: "Calibri", color: MID_GREY })] })],
          })
        ),
      ],
    })
  );

  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [headerRow, ...dataRows],
  });
}

// ─── ALSFRS-R Table ──────────────────────────────────────────────────────────

function alsfrTable() {
  const items = [
    "1. Speech",
    "2. Salivation",
    "3. Swallowing",
    "4. Handwriting",
    "5. Cutting Food / Utensils",
    "6. Dressing / Hygiene",
    "7. Turning in Bed",
    "8. Walking",
    "9. Climbing Stairs",
    "10. Dyspnea",
    "11. Orthopnea",
    "12. Respiratory Insufficiency",
  ];

  const headerRow = new TableRow({
    tableHeader: true,
    children: ["ALSFRS-R Item", "Score (0-4)", "Notes"].map((h) =>
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL },
        children: [new Paragraph({
          children: [new TextRun({ text: h, bold: true, color: WHITE, size: 19, font: "Calibri" })],
          alignment: AlignmentType.CENTER,
        })],
      })
    ),
  });

  const dataRows = items.map((item, i) =>
    new TableRow({
      children: [
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 50, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: item, size: 19, font: "Calibri" })] })],
        }),
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 15, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "___/4", size: 19, font: "Calibri", color: MID_GREY })] })],
        }),
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          width: { size: 35, type: WidthType.PERCENTAGE },
          children: [new Paragraph({ children: [new TextRun({ text: "________________________________", size: 19, font: "Calibri", color: MID_GREY })] })],
        }),
      ],
    })
  );

  const totalRow = new TableRow({
    children: [
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL_LIGHT },
        children: [new Paragraph({ children: [new TextRun({ text: "TOTAL SCORE", bold: true, size: 20, font: "Calibri" })] })],
      }),
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL_LIGHT },
        children: [new Paragraph({ alignment: AlignmentType.CENTER, children: [new TextRun({ text: "___/48", bold: true, size: 20, font: "Calibri", color: TEAL })] })],
      }),
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL_LIGHT },
        children: [new Paragraph({ children: [new TextRun({ text: "Rate of change: ___ pts/month", size: 19, font: "Calibri", italics: true })] })],
      }),
    ],
  });

  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    rows: [headerRow, ...dataRows, totalRow],
  });
}

// ─── Respiratory Table ───────────────────────────────────────────────────────

function respiratoryTable() {
  const params = [
    ["FVC Seated (%predicted)", "____%", "Normal >80%"],
    ["FVC Supine (%predicted)", "____%", "Drop >25% from seated = significant"],
    ["SNIP (cmH₂O)", "____", "<40 = significant impairment"],
    ["MIP (cmH₂O)", "____", "<60 = inspiratory muscle weakness"],
    ["MEP (cmH₂O)", "____", "<60 = impaired cough"],
    ["Peak Cough Flow (L/min)", "____", "<270 = retention risk; <160 = ineffective cough"],
    ["Oxygen Saturation (SpO₂)", "____%", ""],
    ["Respiratory Rate (/min)", "____", "Normal 12-20"],
    ["Nocturnal symptoms", "\u25A1 Yes  \u25A1 No", "Headache / somnolence / orthopnea"],
  ];

  const headerRow = new TableRow({
    tableHeader: true,
    children: ["Parameter", "Value", "Clinical Threshold"].map((h) =>
      new TableCell({
        shading: { type: ShadingType.SOLID, color: TEAL },
        children: [new Paragraph({ children: [new TextRun({ text: h, bold: true, color: WHITE, size: 19, font: "Calibri" })] })],
      })
    ),
  });

  const dataRows = params.map((p, i) =>
    new TableRow({
      children: p.map((cell) =>
        new TableCell({
          shading: { type: ShadingType.SOLID, color: i % 2 === 0 ? GREY_LIGHT : WHITE },
          children: [new Paragraph({ children: [new TextRun({ text: cell, size: 19, font: "Calibri" })] })],
        })
      ),
    })
  );

  return new Table({ width: { size: 100, type: WidthType.PERCENTAGE }, rows: [headerRow, ...dataRows] });
}

// ─── Title Page ──────────────────────────────────────────────────────────────

function titleBlock() {
  return [
    new Paragraph({
      alignment: AlignmentType.CENTER,
      spacing: { before: 200, after: 60 },
      shading: { type: ShadingType.SOLID, color: TEAL },
      children: [
        new TextRun({ text: "  PHYSIOTHERAPY INTAKE & ASSESSMENT FORM", bold: true, size: 34, color: WHITE, font: "Calibri" }),
      ],
    }),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      spacing: { before: 0, after: 40 },
      shading: { type: ShadingType.SOLID, color: "155F6B" },
      children: [
        new TextRun({ text: "  AMYOTROPHIC LATERAL SCLEROSIS (ALS / MND)", bold: true, size: 24, color: WHITE, font: "Calibri" }),
      ],
    }),
    new Paragraph({
      alignment: AlignmentType.CENTER,
      spacing: { before: 60, after: 160 },
      children: [
        new TextRun({ text: "Multidisciplinary ALS Clinic  |  Neurological Physiotherapy Department", size: 19, font: "Calibri", italics: true, color: "555555" }),
      ],
    }),
  ];
}

// ─── Build Document ──────────────────────────────────────────────────────────

const children = [

  // Title
  ...titleBlock(),

  // ═══════════════════════════════════════════
  // SECTION 1 – Patient Demographics
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 1 — PATIENT DEMOGRAPHICS"),
  spacer(),
  labelLine("Patient Name:", "Date of Birth:"),
  labelLine("MRN / Hospital No.:", "Date of Assessment:"),
  labelLine("Referring Physician:", "Diagnosis Date:"),
  labelLine("ALS Clinic / Centre:", "Therapist Name:"),
  checkboxLine("ALS Type", ["Sporadic", "Familial"]),
  checkboxLine("Onset Region", ["Spinal – Upper Limb", "Spinal – Lower Limb", "Bulbar", "Respiratory", "Unknown"]),
  checkboxLine("Genetic Testing", ["Not done", "SOD1", "C9ORF72", "FUS/TLS", "TARDBP", "Other: ________"]),
  labelLine("Emergency Contact Name:", "Relationship:"),
  labelLine("Emergency Contact Phone:", ""),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 2 – Subjective History
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 2 — SUBJECTIVE HISTORY"),
  spacer(),

  subHeader("2.1  Presenting Complaints"),
  ...multiLine("Chief complaint (in patient's own words):"),
  labelLine("Date of first symptom:", "Body region first affected:"),
  labelLine("Disease duration (months):", ""),
  spacer(),

  subHeader("2.2  Symptom Profile"),
  checkboxLine("Current Symptoms", ["Weakness", "Fasciculations", "Muscle cramps", "Spasticity", "Fatigue"]),
  checkboxLine("", ["Dysphagia", "Dysarthria", "Sialorrhea", "Dyspnea", "Orthopnea"]),
  checkboxLine("", ["Foot drop", "Head drop", "Pain / joint stiffness", "Mood changes", "Sleep disturbance"]),
  checkboxLine("Cognitive Changes", ["None", "Mild frontal", "Formal FTD diagnosis"]),
  ...multiLine("Other symptoms / notes:"),
  spacer(),

  subHeader("2.3  Functional History"),
  checkboxLine("Mobility Status", ["Independently ambulant", "Ambulant with aid", "Wheelchair part-time", "Wheelchair full-time", "Bedbound"]),
  checkboxLine("Walking Aid Used", ["None", "Walking stick", "Quad stick", "Rollator", "Forearm crutches", "Walker frame"]),
  checkboxLine("Wheelchair", ["None", "Manual – self-propelled", "Manual – carer-propelled", "Powered – joystick", "Powered – alternative control"]),
  labelLine("Approximate walking distance:", "Falls in past 3 months:"),
  checkboxLine("ADL Independence", ["Fully independent", "Independent with aids", "Requires some assistance", "Fully dependent"]),
  ...multiLine("Activities most limited by ALS (patient-stated priorities):"),
  spacer(),

  subHeader("2.4  Fatigue Assessment"),
  labelLine("Fatigue Severity Scale (FSS) Score:", "(threshold: >36 = significant fatigue)"),
  checkboxLine("Post-exercise fatigue >30 minutes", ["Yes – reduce activity load", "No"]),
  ...multiLine("Fatigue pattern / triggers:"),
  spacer(),

  subHeader("2.5  Pain Assessment"),
  yesNoLine("Current pain"),
  labelLine("Pain location:", "NRS Score (0-10):"),
  checkboxLine("Pain type", ["Spasticity-related", "Joint / mechanical", "Cramps", "Pressure area", "Neuropathic", "Other"]),
  spacer(),

  subHeader("2.6  Respiratory Symptoms"),
  yesNoLine("Dyspnea on exertion"),
  yesNoLine("Orthopnea (breathlessness when lying flat)"),
  yesNoLine("Morning headaches"),
  yesNoLine("Excessive daytime sleepiness"),
  yesNoLine("Interrupted / poor-quality sleep"),
  yesNoLine("Currently on NIV / BiPAP"),
  labelLine("If on NIV – hours/night:", "Interface type:"),
  spacer(),

  subHeader("2.7  Social and Home Environment"),
  checkboxLine("Living Situation", ["Alone", "With spouse/partner", "With family", "Supported accommodation", "Residential care"]),
  checkboxLine("Home Type", ["Single storey", "Multi-storey – lift", "Multi-storey – stairs only", "Other"]),
  yesNoLine("Home modifications in place (grab rails, ramp, stairlift, hospital bed)"),
  labelLine("Primary carer:", "Carer availability (hrs/day):"),
  yesNoLine("Carer trained in manual handling"),
  checkboxLine("Employment Status", ["Working full-time", "Working part-time", "Reduced duties", "Unable to work", "Retired"]),
  spacer(),

  subHeader("2.8  Medical History & Medications"),
  ...multiLine("Relevant past medical history:"),
  labelLine("Current medications relevant to PT:", ""),
  checkboxLine("Disease-modifying therapy", ["Riluzole", "Edaravone", "Tofersen", "AMX0035", "None", "Clinical trial"]),
  checkboxLine("Medications affecting PT", ["Baclofen", "Tizanidine", "Opioids", "Benzodiazepines", "None"]),
  spacer(),

  subHeader("2.9  Patient Goals"),
  ...multiLine("Short-term goals (1-3 months):"),
  ...multiLine("Long-term goals (3-12 months):"),
  ...multiLine("Priority activities to maintain:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 3 – Objective Assessment
  // ═══════════════════════════════════════════
  new Paragraph({ children: [new PageBreak()] }),
  sectionHeader("SECTION 3 — OBJECTIVE ASSESSMENT"),
  spacer(),

  subHeader("3.1  General Observations"),
  ...multiLine("Posture, affect, nutritional status, communication, resting respiratory pattern:"),
  spacer(),

  subHeader("3.2  ALS Functional Rating Scale – Revised (ALSFRS-R)"),
  smallNote("Score each item 0 (unable) to 4 (normal). Total score /48. Rate of decline >1 pt/month = faster progression."),
  spacer(),
  alsfrTable(),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 4 – Muscle Strength
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 4 — MUSCLE STRENGTH (MRC SCALE)"),
  smallNote("MRC Grade: 0 = No contraction | 1 = Flicker | 2 = Movement with gravity eliminated | 3 = Movement against gravity | 4 = Movement against resistance | 5 = Normal"),
  spacer(),
  muscleTable(),
  spacer(),
  labelLine("Grip Strength R (kg):", "Grip Strength L (kg):"),
  labelLine("Pinch Strength R:", "Pinch Strength L:"),
  ...multiLine("Notes on asymmetry, fatigue, pattern of weakness:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 5 – Tone & Spasticity
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 5 — TONE & SPASTICITY"),
  spacer(),
  checkboxLine("UMN Signs Present", ["Hyperreflexia", "Clonus", "Babinski sign", "Hoffman sign", "Spasticity"]),
  checkboxLine("LMN Signs Present", ["Hyporeflexia/areflexia", "Fasciculations", "Muscle wasting"]),
  ...scoreTable("Modified Ashworth Scale (MAS)", [
    "Shoulder / Elbow (R)",
    "Shoulder / Elbow (L)",
    "Wrist / Finger flexors (R)",
    "Wrist / Finger flexors (L)",
    "Hip flexors / Adductors (R)",
    "Hip flexors / Adductors (L)",
    "Ankle plantar flexors (R)",
    "Ankle plantar flexors (L)",
  ]),
  ...multiLine("Functional impact of spasticity:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 6 – Range of Motion
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 6 — RANGE OF MOTION"),
  spacer(),
  labelLine("Shoulder Flexion R:", "L:"),
  labelLine("Shoulder Abduction R:", "L:"),
  labelLine("Elbow Extension R:", "L:"),
  labelLine("Wrist Extension R:", "L:"),
  labelLine("Finger Extension R:", "L:"),
  labelLine("Hip Extension R:", "L:"),
  labelLine("Knee Extension R:", "L:"),
  labelLine("Ankle Dorsiflexion R:", "L:"),
  checkboxLine("Contractures Present", ["None", "Shoulder", "Elbow", "Wrist", "Finger", "Hip", "Knee", "Ankle"]),
  ...multiLine("Notes:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 7 – Respiratory Assessment
  // ═══════════════════════════════════════════
  new Paragraph({ children: [new PageBreak()] }),
  sectionHeader("SECTION 7 — RESPIRATORY ASSESSMENT"),
  spacer(),
  respiratoryTable(),
  spacer(),
  checkboxLine("Paradoxical breathing (abdominal wall movement)", ["Present", "Absent"]),
  checkboxLine("Cough effectiveness", ["Effective", "Weak but functional", "Ineffective – cough assist needed"]),
  checkboxLine("Secretion management", ["Independent", "Requires airway clearance", "Cough assist device in use"]),
  checkboxLine("NIV / BiPAP Recommendation", ["Not yet indicated", "Discuss / plan for initiation", "Initiate – FVC <50% / symptomatic", "Already established"]),
  ...multiLine("Respiratory notes / plan:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 8 – Functional Mobility & Balance
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 8 — FUNCTIONAL MOBILITY & BALANCE"),
  spacer(),
  ...scoreTable("Functional Outcome Measures", [
    "Timed Up and Go (TUG) – seconds",
    "10-Metre Walk Test – seconds / speed (m/s)",
    "6-Minute Walk Test – metres (if safe)",
    "Berg Balance Scale (BBS) – /56",
    "Sit-to-Stand (5 times) – seconds",
  ]),
  checkboxLine("Gait Deviations", ["Foot drop / steppage gait", "Trendelenburg (hip abductor weakness)", "Head drop affecting balance", "Trunk instability", "Reduced arm swing", "None"]),
  checkboxLine("Falls Risk", ["Low (BBS >45)", "Moderate (BBS 36-45)", "High (BBS <36)"]),
  ...multiLine("Fall history details / near-misses:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 9 – Posture & Pressure Care
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 9 — POSTURE & PRESSURE CARE"),
  spacer(),
  checkboxLine("Head Drop", ["Absent", "Mild", "Moderate – collar considered", "Severe – collar required"]),
  checkboxLine("Trunk Control", ["Good", "Mildly impaired", "Significantly impaired – supports required"]),
  checkboxLine("Pressure Areas", ["Intact", "Red areas – at risk", "Grade 1 pressure injury", "Grade 2+", "Refer to tissue viability"]),
  checkboxLine("Seating", ["Standard chair adequate", "Adapted seating", "Tilt-in-space wheelchair", "Custom moulded seating"]),
  checkboxLine("Mattress", ["Standard", "Pressure-relieving foam", "Dynamic air mattress"]),
  ...multiLine("Postural management plan:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 10 – Staging
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 10 — ALS STAGING (KING'S CLINICAL STAGING)"),
  spacer(),
  checkboxLine("Current Stage", [
    "Stage 1 – Ambulant, minor deficits",
    "Stage 2a – Independent, some functional limitation",
    "Stage 2b – Dependent for some ADLs",
    "Stage 3 – Wheelchair, reduced upper limb",
    "Stage 4 – Dependent most ADLs",
    "Stage 5 – End-stage / palliative",
  ]),
  labelLine("ALSFRS-R decline rate (pts/month):", "King's stage at last visit:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 11 – Problem List
  // ═══════════════════════════════════════════
  new Paragraph({ children: [new PageBreak()] }),
  sectionHeader("SECTION 11 — PHYSIOTHERAPY PROBLEM LIST"),
  spacer(),
  ...["1.", "2.", "3.", "4.", "5.", "6."].flatMap((n) => [
    new Paragraph({
      spacing: { before: 60, after: 80 },
      children: [
        new TextRun({ text: n + "  ", bold: true, size: 20, font: "Calibri", color: TEAL }),
        new TextRun({ text: "_".repeat(110), size: 20, font: "Calibri", color: MID_GREY }),
      ],
    }),
  ]),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 12 – Physiotherapy Goals
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 12 — PHYSIOTHERAPY GOALS (SMART)"),
  spacer(),
  subHeader("Short-Term Goals (1-3 months)"),
  ...["1.", "2.", "3."].flatMap((n) => [
    new Paragraph({
      spacing: { before: 60, after: 80 },
      children: [
        new TextRun({ text: n + "  ", bold: true, size: 20, font: "Calibri", color: TEAL }),
        new TextRun({ text: "_".repeat(110), size: 20, font: "Calibri", color: MID_GREY }),
      ],
    }),
  ]),
  spacer(),
  subHeader("Long-Term Goals (3-12 months)"),
  ...["1.", "2.", "3."].flatMap((n) => [
    new Paragraph({
      spacing: { before: 60, after: 80 },
      children: [
        new TextRun({ text: n + "  ", bold: true, size: 20, font: "Calibri", color: TEAL }),
        new TextRun({ text: "_".repeat(110), size: 20, font: "Calibri", color: MID_GREY }),
      ],
    }),
  ]),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 13 – Intervention Plan
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 13 — PHYSIOTHERAPY INTERVENTION PLAN"),
  spacer(),

  subHeader("13.1  Exercise Program"),
  checkboxLine("Aerobic Exercise", ["Stationary cycling", "Walking program", "Hydrotherapy", "Arm ergometer", "None currently"]),
  checkboxLine("Strengthening", ["Moderate resistance – preserved muscles", "Functional strengthening", "None – too weak / fatigued"]),
  checkboxLine("Flexibility / Stretching", ["Active stretching", "Active-assisted ROM", "Passive ROM", "Carer-assisted home program"]),
  labelLine("Exercise frequency (days/week):", "Session duration (mins):"),
  smallNote("Safety rule: post-exercise fatigue must resolve within 30 minutes. Reduce load if this is exceeded."),
  spacer(),

  subHeader("13.2  Respiratory Physiotherapy"),
  checkboxLine("Interventions Planned", ["Inspiratory Muscle Training (IMT)", "Expiratory Muscle Training (EMT)", "Manually Assisted Cough (MAC)"]),
  checkboxLine("", ["Mechanical Insufflation-Exsufflation (Cough Assist)", "Air stacking / LVR", "HFCWO vest therapy"]),
  checkboxLine("", ["NIV education and mask fitting", "Breathing pattern retraining", "Carer education in airway clearance"]),
  spacer(),

  subHeader("13.3  Mobility & Orthotics"),
  checkboxLine("Orthotics / Aids", ["Ankle-foot orthosis (AFO) – R/L", "Cervical collar / head support", "Wrist splint", "Resting hand splint"]),
  checkboxLine("", ["Walking stick", "Rollator", "Forearm crutches", "Manual wheelchair", "Powered wheelchair"]),
  checkboxLine("", ["Stair rail installation advised", "Home modifications referral (OT)", "Ceiling hoist referral"]),
  spacer(),

  subHeader("13.4  Spasticity Management"),
  checkboxLine("Physiotherapy Approach", ["Slow sustained stretching", "Positioning program", "Cryotherapy", "Hydrotherapy", "Splinting"]),
  checkboxLine("Referral for", ["Botulinum toxin (focal spasticity)", "Intrathecal baclofen review", "None"]),
  spacer(),

  subHeader("13.5  Fatigue & Pain Management"),
  checkboxLine("Fatigue Strategies", ["Activity pacing", "Energy conservation education", "Prioritisation of high-energy tasks to morning", "Sleep hygiene"]),
  checkboxLine("Pain Management", ["Heat therapy", "TENS", "Joint ROM for stiffness", "Positioning / offloading", "Referral to pain team"]),
  spacer(),

  subHeader("13.6  Carer / Family Education"),
  checkboxLine("Education Provided On", ["Safe manual handling", "Passive ROM home program", "Cough assist technique", "NIV use and care", "Pressure area prevention"]),
  checkboxLine("", ["Fall prevention", "Adaptive equipment use", "Signs of respiratory deterioration", "Caregiver self-care / respite resources"]),
  spacer(),

  subHeader("13.7  Telehealth / Home Program"),
  yesNoLine("Telehealth appropriate for this patient"),
  yesNoLine("Written home exercise program provided"),
  labelLine("Home program frequency:", "Review via telehealth:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 14 – MDT Referrals
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 14 — MDT REFERRALS & COORDINATION"),
  spacer(),
  checkboxLine("Referrals Made", ["Occupational Therapy", "Speech & Language Therapy", "Dietitian / Nutritionist", "Respiratory Physician"]),
  checkboxLine("", ["Palliative Care", "Psychology / Psychiatry", "Social Work", "Orthotics", "Community / Home PT"]),
  ...multiLine("Referral notes / reason:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 15 – Follow-Up Plan
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 15 — FOLLOW-UP & REVIEW PLAN"),
  spacer(),
  checkboxLine("Follow-up Frequency", ["Every 2 weeks", "Monthly", "Every 2 months", "Every 3 months", "As needed"]),
  labelLine("Next review date:", "Next ALSFRS-R to be completed:"),
  labelLine("Next respiratory function test:", "Planned reassessment of goals:"),
  ...multiLine("Additional notes / special considerations:"),
  spacer(),

  // ═══════════════════════════════════════════
  // SECTION 16 – Signature
  // ═══════════════════════════════════════════
  sectionHeader("SECTION 16 — CLINICIAN SIGN-OFF"),
  spacer(),
  labelLine("Physiotherapist Name (Print):", "Designation:"),
  labelLine("Signature:", "Date:"),
  labelLine("Countersigned (if applicable):", "Date:"),
  smallNote("This form is a clinical record. Handle in accordance with patient data protection and confidentiality guidelines."),
  spacer(),
];

// ─── Assemble Document ───────────────────────────────────────────────────────

const doc = new Document({
  creator: "ALS Physiotherapy Clinic",
  title: "ALS Physiotherapy Intake & Assessment Form",
  description: "Structured physiotherapy intake and assessment form for patients with Amyotrophic Lateral Sclerosis",
  styles: {
    default: {
      document: {
        run: { font: "Calibri", size: 20 },
      },
    },
  },
  sections: [
    {
      properties: {
        page: {
          margin: { top: 720, bottom: 720, left: 900, right: 900 },
        },
      },
      headers: {
        default: new Header({
          children: [
            new Paragraph({
              alignment: AlignmentType.RIGHT,
              spacing: { after: 0 },
              children: [
                new TextRun({ text: "ALS Physiotherapy Intake Form  |  Page ", size: 17, font: "Calibri", color: "888888" }),
                new TextRun({ children: [PageNumber.CURRENT], size: 17, font: "Calibri", color: "888888" }),
                new TextRun({ text: " of ", size: 17, font: "Calibri", color: "888888" }),
                new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 17, font: "Calibri", color: "888888" }),
              ],
            }),
          ],
        }),
      },
      footers: {
        default: new Footer({
          children: [
            new Paragraph({
              alignment: AlignmentType.CENTER,
              children: [
                new TextRun({
                  text: "CONFIDENTIAL – Clinical Record  |  ALS / Motor Neuron Disease Service",
                  size: 16, font: "Calibri", color: "888888", italics: true,
                }),
              ],
            }),
          ],
        }),
      },
      children,
    },
  ],
});

Packer.toBuffer(doc).then((buffer) => {
  fs.writeFileSync("/home/daytona/workspace/als-intake-form/ALS_Physiotherapy_Intake_Form.docx", buffer);
  console.log("SUCCESS: Form generated at /home/daytona/workspace/als-intake-form/ALS_Physiotherapy_Intake_Form.docx");
});

cd /home/daytona/workspace/als-intake-form && node generate_form.js

python /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/worksp…

python -c " import zipfile, os path = '/home/daytona/workspace/als-intake-form/A…