{"id":49754,"date":"2026-02-03T16:56:53","date_gmt":"2026-02-03T21:56:53","guid":{"rendered":"https:\/\/cdequestre.com\/?page_id=49754"},"modified":"2026-02-17T16:51:40","modified_gmt":"2026-02-17T21:51:40","slug":"questionnaire-medical","status":"publish","type":"page","link":"https:\/\/cdequestre.com\/en\/questionnaire-medical\/","title":{"rendered":"Medical questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"49754\" class=\"elementor elementor-49754 elementor-49328\">\n\t\t\t\t<section class=\"elementor-element elementor-element-3c0030d e-flex e-con-boxed cmsmasters-bg-hide-none cmsmasters-bg-hide-none cmsmasters-block-default e-con e-parent\" data-id=\"3c0030d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-b96abd9 e-con-full e-flex cmsmasters-block-default elementor-invisible e-con e-child\" data-id=\"b96abd9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;cmsmasters-fade-in-up&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-b035f22 e-flex e-con-boxed cmsmasters-block-default e-con e-child\" data-id=\"b035f22\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4a5026e cmsmasters-block-default cmsmasters-sticky-default elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"4a5026e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;cmsmasters-fade-in-up&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">MEDICAL QUESTIONNAIRE<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b3e9277 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-shortcode\" data-id=\"b3e9277\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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be left unchanged.<\/div><\/li><li id=\"field_6_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#58c6c3;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATIONS<\/div><\/li><li id=\"field_6_173\" class=\"gfield gfield--type-text gfield--input-type-text rougerouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_6_173'><span class='gform-field-label__text'>* Veuillez porter attention<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_6_173' type='text' value='* OUI * ' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_11\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_175\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_175'><span class='gform-field-label__text'>Age<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_6_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_6_35' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_6_35_2_container'><label for='input_6_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_6_35_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_6_35_1_container'><label for='input_6_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_6_35_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_6_35_3_container'><label for='input_6_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_6_35_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_13'>\n\t\t\t<li class='gchoice gchoice_6_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='M'  id='choice_6_13_0'    \/>\n\t\t\t\t<label for='choice_6_13_0' id='label_6_13_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='F'  id='choice_6_13_1'    \/>\n\t\t\t\t<label for='choice_6_13_1' id='label_6_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Other'  id='choice_6_13_2'    \/>\n\t\t\t\t<label for='choice_6_13_2' id='label_6_13_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_123\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_123'><span class='gform-field-label__text'>Health Ins. No.<\/span><\/label><div class='gfield_description' id='gfield_description_6_123'>(To be completed for children aged 10 and under)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_6_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_6_123\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_254\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_254'><span class='gform-field-label__text'>Expiration<\/span><\/label><div class='gfield_description' id='gfield_description_6_254'>(MM\/YYYY)<\/div><div class='ginput_container ginput_container_text'><input name='input_254' id='input_6_254' type='text' value='' class='medium'  aria-describedby=\"gfield_description_6_254\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_36'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_6_36' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_38'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_6_38' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_37\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_6_37' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_34\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_6_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_34_1' id='input_6_34_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_6_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_34_3' id='input_6_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_34_4_container' >\n                                        <select name='input_34.4' id='input_6_34_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_6_34_4' id='input_6_34_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_6_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_34_5' id='input_6_34_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_6_34_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you under 18?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_126'>\n\t\t\t<li class='gchoice gchoice_6_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_6_126_0'    \/>\n\t\t\t\t<label for='choice_6_126_0' id='label_6_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_6_126_1'    \/>\n\t\t\t\t<label for='choice_6_126_1' id='label_6_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_46\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'><span class='gform-field-label__text'>Father&#039;s Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_127\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_127'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_127' id='input_6_127' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_128\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_128'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_6_128' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_129\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_129'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_6_129' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_130\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_130'><span class='gform-field-label__text'>Mother&#039;s Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_6_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_133\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_133' id='input_6_133' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_132\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_132'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_6_132' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_131\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_131'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_6_131' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Who is responsible for the fees?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_134'>\n\t\t\t<li class='gchoice gchoice_6_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Father'  id='choice_6_134_0'    \/>\n\t\t\t\t<label for='choice_6_134_0' id='label_6_134_0' class='gform-field-label gform-field-label--type-inline'>Father<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Mother'  id='choice_6_134_1'    \/>\n\t\t\t\t<label for='choice_6_134_1' id='label_6_134_1' class='gform-field-label gform-field-label--type-inline'>Mother<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_134_2'>\n\t\t\t\t<input name='input_134' type='radio' value='Other'  id='choice_6_134_2'    \/>\n\t\t\t\t<label for='choice_6_134_2' id='label_6_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_47\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_47'><span class='gform-field-label__text'>Specify Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_6_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_40\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_40'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_6_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_179\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>For emergencies, call:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name no_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_179'>\n                            \n                            <span id='input_6_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_6_179_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_179_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            <span id='input_6_179_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.4' id='input_6_179_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_179_4' class='gform-field-label gform-field-label--type-sub '>Relationship to patient<\/label>\n                                                <\/span>\n                            \n                            \n                        <\/div><\/li><li id=\"field_6_180\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_180'><span class='gform-field-label__text'>Main Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_180' id='input_6_180' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_181\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_181'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_181' id='input_6_181' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#58c6c3;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL INFORMATION<\/div><\/li><li id=\"field_6_139\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_139'><span class='gform-field-label__text'>Reason for today\u2019s visit<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_6_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Last visit :<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_15'>\n\t\t\t<li class='gchoice gchoice_6_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='0-6 month'  id='choice_6_15_0'    \/>\n\t\t\t\t<label for='choice_6_15_0' id='label_6_15_0' class='gform-field-label gform-field-label--type-inline'>0-6 month<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='6-12 month'  id='choice_6_15_1'    \/>\n\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>6-12 month<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='+12 month'  id='choice_6_15_2'    \/>\n\t\t\t\t<label for='choice_6_15_2' id='label_6_15_2' class='gform-field-label gform-field-label--type-inline'>+12 month<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_182\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_182'><span class='gform-field-label__text'>Treatment(s) received<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_6_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With panoramic radiographs (large x-ray)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_142'>\n\t\t\t<li class='gchoice gchoice_6_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_6_142_0'    \/>\n\t\t\t\t<label for='choice_6_142_0' id='label_6_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_6_142_1'    \/>\n\t\t\t\t<label for='choice_6_142_1' id='label_6_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With intraoral radiographs (small x-rays)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_143'>\n\t\t\t<li class='gchoice gchoice_6_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_6_143_0'    \/>\n\t\t\t\t<label for='choice_6_143_0' id='label_6_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_6_143_1'    \/>\n\t\t\t\t<label for='choice_6_143_1' id='label_6_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you fear dental treatments?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_145'>\n\t\t\t<li class='gchoice gchoice_6_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Not at all'  id='choice_6_145_0'    \/>\n\t\t\t\t<label for='choice_6_145_0' id='label_6_145_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='A little'  id='choice_6_145_1'    \/>\n\t\t\t\t<label for='choice_6_145_1' id='label_6_145_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_145_2'>\n\t\t\t\t<input name='input_145' type='radio' value='Very much'  id='choice_6_145_2'    \/>\n\t\t\t\t<label for='choice_6_145_2' id='label_6_145_2' class='gform-field-label gform-field-label--type-inline'>Very much<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_136\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_136'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_6_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Would you like to speak privately with your dentist?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_183'>\n\t\t\t<li class='gchoice gchoice_6_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='Yes'  id='choice_6_183_0'    \/>\n\t\t\t\t<label for='choice_6_183_0' id='label_6_183_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_6_183_1'    \/>\n\t\t\t\t<label for='choice_6_183_1' id='label_6_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_184\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_184'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_6_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you being treated by a physician?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_185'>\n\t\t\t<li class='gchoice gchoice_6_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='Yes'  id='choice_6_185_0'    \/>\n\t\t\t\t<label for='choice_6_185_0' id='label_6_185_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_6_185_1'    \/>\n\t\t\t\t<label for='choice_6_185_1' id='label_6_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_186\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_186'><span class='gform-field-label__text'>Physician&#039;s Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_6_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_256\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_256'><span class='gform-field-label__text'>Physician Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_256' id='input_6_256' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_6_255\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_255'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_6_255' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you ever had surgery or been hospitalized?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_187'>\n\t\t\t<li class='gchoice gchoice_6_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='Yes'  id='choice_6_187_0'    \/>\n\t\t\t\t<label for='choice_6_187_0' id='label_6_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_6_187_1'    \/>\n\t\t\t\t<label for='choice_6_187_1' id='label_6_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_188\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_188'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_6_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have joint prostheses (hip, knee, etc.)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_189'>\n\t\t\t<li class='gchoice gchoice_6_189_0'>\n\t\t\t\t<input name='input_189' type='radio' value='Yes'  id='choice_6_189_0'    \/>\n\t\t\t\t<label for='choice_6_189_0' id='label_6_189_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_189_1'>\n\t\t\t\t<input name='input_189' type='radio' value='No'  id='choice_6_189_1'    \/>\n\t\t\t\t<label for='choice_6_189_1' id='label_6_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_190\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_190'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_6_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_191\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you gained or lost a lot of weight recently?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_191'>\n\t\t\t<li class='gchoice gchoice_6_191_0'>\n\t\t\t\t<input name='input_191' type='radio' value='Yes'  id='choice_6_191_0'    \/>\n\t\t\t\t<label for='choice_6_191_0' id='label_6_191_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_191_1'>\n\t\t\t\t<input name='input_191' type='radio' value='No'  id='choice_6_191_1'    \/>\n\t\t\t\t<label for='choice_6_191_1' id='label_6_191_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_192\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_192'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_6_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking natural or homeopathic products?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_193'>\n\t\t\t<li class='gchoice gchoice_6_193_0'>\n\t\t\t\t<input name='input_193' type='radio' value='Yes'  id='choice_6_193_0'    \/>\n\t\t\t\t<label for='choice_6_193_0' id='label_6_193_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_193_1'>\n\t\t\t\t<input name='input_193' type='radio' value='No'  id='choice_6_193_1'    \/>\n\t\t\t\t<label for='choice_6_193_1' id='label_6_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_194\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_194'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_6_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you pregnant?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_195'>\n\t\t\t<li class='gchoice gchoice_6_195_0'>\n\t\t\t\t<input name='input_195' type='radio' value='Yes'  id='choice_6_195_0'    \/>\n\t\t\t\t<label for='choice_6_195_0' id='label_6_195_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_195_1'>\n\t\t\t\t<input name='input_195' type='radio' value='No'  id='choice_6_195_1'    \/>\n\t\t\t\t<label for='choice_6_195_1' id='label_6_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you breastfeeding?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_196'>\n\t\t\t<li class='gchoice gchoice_6_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='Yes'  id='choice_6_196_0'    \/>\n\t\t\t\t<label for='choice_6_196_0' id='label_6_196_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='No'  id='choice_6_196_1'    \/>\n\t\t\t\t<label for='choice_6_196_1' id='label_6_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_197\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking medication?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_197'>\n\t\t\t<li class='gchoice gchoice_6_197_0'>\n\t\t\t\t<input name='input_197' type='radio' value='Yes'  id='choice_6_197_0'    \/>\n\t\t\t\t<label for='choice_6_197_0' id='label_6_197_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_197_1'>\n\t\t\t\t<input name='input_197' type='radio' value='No'  id='choice_6_197_1'    \/>\n\t\t\t\t<label for='choice_6_197_1' id='label_6_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking birth control or hormones<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_198'>\n\t\t\t<li class='gchoice gchoice_6_198_0'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes birth control'  id='choice_6_198_0'    \/>\n\t\t\t\t<label for='choice_6_198_0' id='label_6_198_0' class='gform-field-label gform-field-label--type-inline'>Yes birth control<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_198_1'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes hormones'  id='choice_6_198_1'    \/>\n\t\t\t\t<label for='choice_6_198_1' id='label_6_198_1' class='gform-field-label gform-field-label--type-inline'>Yes hormones<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_198_2'>\n\t\t\t\t<input name='input_198' type='radio' value='No'  id='choice_6_198_2'    \/>\n\t\t\t\t<label for='choice_6_198_2' id='label_6_198_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_199'><span class='gform-field-label__text'>Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_6_199' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_138\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#58c6c3;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR CURRENT CONDITION<\/div><\/li><li id=\"field_6_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#d6f1f1;color:#58c6c3;font-weight:bold;font-size:16px;\">Blood disorders<\/div><\/li><li id=\"field_6_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>(hemophilia, anemia, prolonged bleeding)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_55'>\n\t\t\t<li class='gchoice gchoice_6_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Yes'  id='choice_6_55_0'    \/>\n\t\t\t\t<label for='choice_6_55_0' id='label_6_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_6_55_1'    \/>\n\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#d6f1f1;color:#58c6c3;font-weight:bold;font-size:16px;\">Heart conditions<\/div><\/li><li id=\"field_6_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Infarction (heart attack), angina, surgery, etc.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_54'>\n\t\t\t<li class='gchoice gchoice_6_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_6_54_0'    \/>\n\t\t\t\t<label for='choice_6_54_0' id='label_6_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_6_54_1'    \/>\n\t\t\t\t<label for='choice_6_54_1' id='label_6_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Heart infection (endocarditis)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_202'>\n\t\t\t<li class='gchoice gchoice_6_202_0'>\n\t\t\t\t<input name='input_202' type='radio' value='Yes'  id='choice_6_202_0'    \/>\n\t\t\t\t<label for='choice_6_202_0' id='label_6_202_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_202_1'>\n\t\t\t\t<input name='input_202' type='radio' value='No'  id='choice_6_202_1'    \/>\n\t\t\t\t<label for='choice_6_202_1' id='label_6_202_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_203\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Surgery to replace or repair a valve \/cusp<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_203'>\n\t\t\t<li class='gchoice gchoice_6_203_0'>\n\t\t\t\t<input name='input_203' type='radio' value='Yes'  id='choice_6_203_0'    \/>\n\t\t\t\t<label for='choice_6_203_0' id='label_6_203_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_203_1'>\n\t\t\t\t<input name='input_203' type='radio' value='No'  id='choice_6_203_1'    \/>\n\t\t\t\t<label for='choice_6_203_1' id='label_6_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_204\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#d6f1f1;color:#58c6c3;font-weight:bold;font-size:16px;\">Other<\/div><\/li><li id=\"field_6_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Blood pressure<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_57'>\n\t\t\t<li class='gchoice gchoice_6_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - Low'  id='choice_6_57_0'    \/>\n\t\t\t\t<label for='choice_6_57_0' id='label_6_57_0' class='gform-field-label gform-field-label--type-inline'>Yes - Low<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - High'  id='choice_6_57_1'    \/>\n\t\t\t\t<label for='choice_6_57_1' id='label_6_57_1' class='gform-field-label gform-field-label--type-inline'>Yes - High<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_6_57_2'    \/>\n\t\t\t\t<label for='choice_6_57_2' id='label_6_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Dizziness, fainting<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_205'>\n\t\t\t<li class='gchoice gchoice_6_205_0'>\n\t\t\t\t<input name='input_205' type='radio' value='Yes'  id='choice_6_205_0'    \/>\n\t\t\t\t<label for='choice_6_205_0' id='label_6_205_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_205_1'>\n\t\t\t\t<input name='input_205' type='radio' value='No'  id='choice_6_205_1'    \/>\n\t\t\t\t<label for='choice_6_205_1' id='label_6_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Frequent headaches<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_206'>\n\t\t\t<li class='gchoice gchoice_6_206_0'>\n\t\t\t\t<input name='input_206' type='radio' value='Yes'  id='choice_6_206_0'    \/>\n\t\t\t\t<label for='choice_6_206_0' id='label_6_206_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_206_1'>\n\t\t\t\t<input name='input_206' type='radio' value='No'  id='choice_6_206_1'    \/>\n\t\t\t\t<label for='choice_6_206_1' id='label_6_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_207\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Jaw pain<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_207'>\n\t\t\t<li class='gchoice gchoice_6_207_0'>\n\t\t\t\t<input name='input_207' type='radio' value='Yes'  id='choice_6_207_0'    \/>\n\t\t\t\t<label for='choice_6_207_0' id='label_6_207_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_207_1'>\n\t\t\t\t<input name='input_207' type='radio' value='No'  id='choice_6_207_1'    \/>\n\t\t\t\t<label for='choice_6_207_1' id='label_6_207_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Liver disorders (hepatitis A, B, C. cirrhosis, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_208'>\n\t\t\t<li class='gchoice gchoice_6_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='Yes'  id='choice_6_208_0'    \/>\n\t\t\t\t<label for='choice_6_208_0' id='label_6_208_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='No'  id='choice_6_208_1'    \/>\n\t\t\t\t<label for='choice_6_208_1' id='label_6_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Digestive system disorders or diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_209'>\n\t\t\t<li class='gchoice gchoice_6_209_0'>\n\t\t\t\t<input name='input_209' type='radio' value='Yes'  id='choice_6_209_0'    \/>\n\t\t\t\t<label for='choice_6_209_0' id='label_6_209_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_209_1'>\n\t\t\t\t<input name='input_209' type='radio' value='No'  id='choice_6_209_1'    \/>\n\t\t\t\t<label for='choice_6_209_1' id='label_6_209_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_210\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_210'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_6_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_211\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Stomach disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_211'>\n\t\t\t<li class='gchoice gchoice_6_211_0'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Ulcer'  id='choice_6_211_0'    \/>\n\t\t\t\t<label for='choice_6_211_0' id='label_6_211_0' class='gform-field-label gform-field-label--type-inline'>Yes, Ulcer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_211_1'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Reflux'  id='choice_6_211_1'    \/>\n\t\t\t\t<label for='choice_6_211_1' id='label_6_211_1' class='gform-field-label gform-field-label--type-inline'>Yes, Reflux<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_211_2'>\n\t\t\t\t<input name='input_211' type='radio' value='No'  id='choice_6_211_2'    \/>\n\t\t\t\t<label for='choice_6_211_2' id='label_6_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_212\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Kidney disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_212'>\n\t\t\t<li class='gchoice gchoice_6_212_0'>\n\t\t\t\t<input name='input_212' type='radio' value='Yes'  id='choice_6_212_0'    \/>\n\t\t\t\t<label for='choice_6_212_0' id='label_6_212_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_212_1'>\n\t\t\t\t<input name='input_212' type='radio' value='No'  id='choice_6_212_1'    \/>\n\t\t\t\t<label for='choice_6_212_1' id='label_6_212_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_213\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Diabetes<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_213'>\n\t\t\t<li class='gchoice gchoice_6_213_0'>\n\t\t\t\t<input name='input_213' type='radio' value='Yes'  id='choice_6_213_0'    \/>\n\t\t\t\t<label for='choice_6_213_0' id='label_6_213_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_213_1'>\n\t\t\t\t<input name='input_213' type='radio' value='No'  id='choice_6_213_1'    \/>\n\t\t\t\t<label for='choice_6_213_1' id='label_6_213_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_214\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Thyroid disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_214'>\n\t\t\t<li class='gchoice gchoice_6_214_0'>\n\t\t\t\t<input name='input_214' type='radio' value='Yes'  id='choice_6_214_0'    \/>\n\t\t\t\t<label for='choice_6_214_0' id='label_6_214_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_214_1'>\n\t\t\t\t<input name='input_214' type='radio' value='No'  id='choice_6_214_1'    \/>\n\t\t\t\t<label for='choice_6_214_1' id='label_6_214_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_217\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Cancer (tumour)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_217'>\n\t\t\t<li class='gchoice gchoice_6_217_0'>\n\t\t\t\t<input name='input_217' type='radio' value='Yes'  id='choice_6_217_0'    \/>\n\t\t\t\t<label for='choice_6_217_0' id='label_6_217_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_217_1'>\n\t\t\t\t<input name='input_217' type='radio' value='No'  id='choice_6_217_1'    \/>\n\t\t\t\t<label for='choice_6_217_1' id='label_6_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_218\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_218'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_6_218' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Radiotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_219'>\n\t\t\t<li class='gchoice gchoice_6_219_0'>\n\t\t\t\t<input name='input_219' type='radio' value='Yes'  id='choice_6_219_0'    \/>\n\t\t\t\t<label for='choice_6_219_0' id='label_6_219_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_219_1'>\n\t\t\t\t<input name='input_219' type='radio' value='No'  id='choice_6_219_1'    \/>\n\t\t\t\t<label for='choice_6_219_1' id='label_6_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_220\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chemotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_220'>\n\t\t\t<li class='gchoice gchoice_6_220_0'>\n\t\t\t\t<input name='input_220' type='radio' value='Yes'  id='choice_6_220_0'    \/>\n\t\t\t\t<label for='choice_6_220_0' id='label_6_220_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_220_1'>\n\t\t\t\t<input name='input_220' type='radio' value='No'  id='choice_6_220_1'    \/>\n\t\t\t\t<label for='choice_6_220_1' id='label_6_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you suffer from dry mouth?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_221'>\n\t\t\t<li class='gchoice gchoice_6_221_0'>\n\t\t\t\t<input name='input_221' type='radio' value='Yes'  id='choice_6_221_0'    \/>\n\t\t\t\t<label for='choice_6_221_0' id='label_6_221_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_221_1'>\n\t\t\t\t<input name='input_221' type='radio' value='No'  id='choice_6_221_1'    \/>\n\t\t\t\t<label for='choice_6_221_1' id='label_6_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_222\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sexually transmitted or blood-borne infections (STBBI)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_222'>\n\t\t\t<li class='gchoice gchoice_6_222_0'>\n\t\t\t\t<input name='input_222' type='radio' value='Yes'  id='choice_6_222_0'    \/>\n\t\t\t\t<label for='choice_6_222_0' id='label_6_222_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_222_1'>\n\t\t\t\t<input name='input_222' type='radio' value='No'  id='choice_6_222_1'    \/>\n\t\t\t\t<label for='choice_6_222_1' id='label_6_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_223\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_223'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_6_223' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_224\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Skin diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_224'>\n\t\t\t<li class='gchoice gchoice_6_224_0'>\n\t\t\t\t<input name='input_224' type='radio' value='Yes'  id='choice_6_224_0'    \/>\n\t\t\t\t<label for='choice_6_224_0' id='label_6_224_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_224_1'>\n\t\t\t\t<input name='input_224' type='radio' value='No'  id='choice_6_224_1'    \/>\n\t\t\t\t<label for='choice_6_224_1' id='label_6_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Eye disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_225'>\n\t\t\t<li class='gchoice gchoice_6_225_0'>\n\t\t\t\t<input name='input_225' type='radio' value='Yes'  id='choice_6_225_0'    \/>\n\t\t\t\t<label for='choice_6_225_0' id='label_6_225_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_225_1'>\n\t\t\t\t<input name='input_225' type='radio' value='No'  id='choice_6_225_1'    \/>\n\t\t\t\t<label for='choice_6_225_1' id='label_6_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_226\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Earaches<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_226'>\n\t\t\t<li class='gchoice gchoice_6_226_0'>\n\t\t\t\t<input name='input_226' type='radio' value='Yes'  id='choice_6_226_0'    \/>\n\t\t\t\t<label for='choice_6_226_0' id='label_6_226_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_226_1'>\n\t\t\t\t<input name='input_226' type='radio' value='No'  id='choice_6_226_1'    \/>\n\t\t\t\t<label for='choice_6_226_1' id='label_6_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_227\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Arthritis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_227'>\n\t\t\t<li class='gchoice gchoice_6_227_0'>\n\t\t\t\t<input name='input_227' type='radio' value='Yes'  id='choice_6_227_0'    \/>\n\t\t\t\t<label for='choice_6_227_0' id='label_6_227_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_227_1'>\n\t\t\t\t<input name='input_227' type='radio' value='No'  id='choice_6_227_1'    \/>\n\t\t\t\t<label for='choice_6_227_1' id='label_6_227_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chronic pain<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_231'>\n\t\t\t<li class='gchoice gchoice_6_231_0'>\n\t\t\t\t<input name='input_231' type='radio' value='Yes'  id='choice_6_231_0'    \/>\n\t\t\t\t<label for='choice_6_231_0' id='label_6_231_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_231_1'>\n\t\t\t\t<input name='input_231' type='radio' value='No'  id='choice_6_231_1'    \/>\n\t\t\t\t<label for='choice_6_231_1' id='label_6_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_232\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Epilepsy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_232'>\n\t\t\t<li class='gchoice gchoice_6_232_0'>\n\t\t\t\t<input name='input_232' type='radio' value='Yes'  id='choice_6_232_0'    \/>\n\t\t\t\t<label for='choice_6_232_0' id='label_6_232_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_232_1'>\n\t\t\t\t<input name='input_232' type='radio' value='No'  id='choice_6_232_1'    \/>\n\t\t\t\t<label for='choice_6_232_1' id='label_6_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_235\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Frequent colds or sinusitis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_235'>\n\t\t\t<li class='gchoice gchoice_6_235_0'>\n\t\t\t\t<input name='input_235' type='radio' value='Yes'  id='choice_6_235_0'    \/>\n\t\t\t\t<label for='choice_6_235_0' id='label_6_235_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_235_1'>\n\t\t\t\t<input name='input_235' type='radio' value='No'  id='choice_6_235_1'    \/>\n\t\t\t\t<label for='choice_6_235_1' id='label_6_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_237\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Asthma<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_237'>\n\t\t\t<li class='gchoice gchoice_6_237_0'>\n\t\t\t\t<input name='input_237' type='radio' value='Yes'  id='choice_6_237_0'    \/>\n\t\t\t\t<label for='choice_6_237_0' id='label_6_237_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_237_1'>\n\t\t\t\t<input name='input_237' type='radio' value='No'  id='choice_6_237_1'    \/>\n\t\t\t\t<label for='choice_6_237_1' id='label_6_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Hay fever \/ seasonal allergies<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_238'>\n\t\t\t<li class='gchoice gchoice_6_238_0'>\n\t\t\t\t<input name='input_238' type='radio' value='Yes'  id='choice_6_238_0'    \/>\n\t\t\t\t<label for='choice_6_238_0' id='label_6_238_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_238_1'>\n\t\t\t\t<input name='input_238' type='radio' value='No'  id='choice_6_238_1'    \/>\n\t\t\t\t<label for='choice_6_238_1' id='label_6_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Tuberculosis or lung disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_236'>\n\t\t\t<li class='gchoice gchoice_6_236_0'>\n\t\t\t\t<input name='input_236' type='radio' value='Yes'  id='choice_6_236_0'    \/>\n\t\t\t\t<label for='choice_6_236_0' id='label_6_236_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_236_1'>\n\t\t\t\t<input name='input_236' type='radio' value='No'  id='choice_6_236_1'    \/>\n\t\t\t\t<label for='choice_6_236_1' id='label_6_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_233\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Nervous system disorders or diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_233'>\n\t\t\t<li class='gchoice gchoice_6_233_0'>\n\t\t\t\t<input name='input_233' type='radio' value='Yes'  id='choice_6_233_0'    \/>\n\t\t\t\t<label for='choice_6_233_0' id='label_6_233_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_233_1'>\n\t\t\t\t<input name='input_233' type='radio' value='No'  id='choice_6_233_1'    \/>\n\t\t\t\t<label for='choice_6_233_1' id='label_6_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Mental disorders or illnesses<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_234'>\n\t\t\t<li class='gchoice gchoice_6_234_0'>\n\t\t\t\t<input name='input_234' type='radio' value='Yes'  id='choice_6_234_0'    \/>\n\t\t\t\t<label for='choice_6_234_0' id='label_6_234_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_234_1'>\n\t\t\t\t<input name='input_234' type='radio' value='No'  id='choice_6_234_1'    \/>\n\t\t\t\t<label for='choice_6_234_1' id='label_6_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_228\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Osteoporosis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_228'>\n\t\t\t<li class='gchoice gchoice_6_228_0'>\n\t\t\t\t<input name='input_228' type='radio' value='Yes'  id='choice_6_228_0'    \/>\n\t\t\t\t<label for='choice_6_228_0' id='label_6_228_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_228_1'>\n\t\t\t\t<input name='input_228' type='radio' value='No'  id='choice_6_228_1'    \/>\n\t\t\t\t<label for='choice_6_228_1' id='label_6_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Annual or monthly injection<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_230'>\n\t\t\t<li class='gchoice gchoice_6_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='Yes'  id='choice_6_230_0'    \/>\n\t\t\t\t<label for='choice_6_230_0' id='label_6_230_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_6_230_1'    \/>\n\t\t\t\t<label for='choice_6_230_1' id='label_6_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_229\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Prevention \/ treatment (e.g.: tablets)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_229'>\n\t\t\t<li class='gchoice gchoice_6_229_0'>\n\t\t\t\t<input name='input_229' type='radio' value='Yes'  id='choice_6_229_0'    \/>\n\t\t\t\t<label for='choice_6_229_0' id='label_6_229_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_229_1'>\n\t\t\t\t<input name='input_229' type='radio' value='No'  id='choice_6_229_1'    \/>\n\t\t\t\t<label for='choice_6_229_1' id='label_6_229_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_240\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Allergy or manifestation with products containing:<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_240'><li class='gchoice gchoice_6_240_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.1' type='checkbox'  value='Latex'  id='choice_6_240_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_1' id='label_6_240_1' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.2' type='checkbox'  value='Penicillin'  id='choice_6_240_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_2' id='label_6_240_2' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.3' type='checkbox'  value='Other antibiotics'  id='choice_6_240_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_3' id='label_6_240_3' class='gform-field-label gform-field-label--type-inline'>Other antibiotics<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.4' type='checkbox'  value='Codeine'  id='choice_6_240_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_4' id='label_6_240_4' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.5' type='checkbox'  value='Aspirin'  id='choice_6_240_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_5' id='label_6_240_5' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.6' type='checkbox'  value='Sulfonamides'  id='choice_6_240_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_6' id='label_6_240_6' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.7' type='checkbox'  value='Anesthetic'  id='choice_6_240_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_7' id='label_6_240_7' class='gform-field-label gform-field-label--type-inline'>Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.8' type='checkbox'  value='Food'  id='choice_6_240_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_8' id='label_6_240_8' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.9' type='checkbox'  value='Iodine-containing products'  id='choice_6_240_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_9' id='label_6_240_9' class='gform-field-label gform-field-label--type-inline'>Iodine-containing products<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.11' type='checkbox'  value='Other'  id='choice_6_240_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_11' id='label_6_240_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_241\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_241'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_6_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_120\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gf_left field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'><span class='gform-field-label__text'>Other medical conditions that should be mentioned<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_6_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_242\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#d6f1f1;color:#58c6c3;font-weight:bold;font-size:16px;\">Other aspects<\/div><\/li><li id=\"field_6_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you snore?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_243'>\n\t\t\t<li class='gchoice gchoice_6_243_0'>\n\t\t\t\t<input name='input_243' type='radio' value='Yes'  id='choice_6_243_0'    \/>\n\t\t\t\t<label for='choice_6_243_0' id='label_6_243_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_243_1'>\n\t\t\t\t<input name='input_243' type='radio' value='No'  id='choice_6_243_1'    \/>\n\t\t\t\t<label for='choice_6_243_1' id='label_6_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you suffer from sleep apnea?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_244'>\n\t\t\t<li class='gchoice gchoice_6_244_0'>\n\t\t\t\t<input name='input_244' type='radio' value='Yes'  id='choice_6_244_0'    \/>\n\t\t\t\t<label for='choice_6_244_0' id='label_6_244_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_244_1'>\n\t\t\t\t<input name='input_244' type='radio' value='No'  id='choice_6_244_1'    \/>\n\t\t\t\t<label for='choice_6_244_1' id='label_6_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you smoke?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_245'>\n\t\t\t<li class='gchoice gchoice_6_245_0'>\n\t\t\t\t<input name='input_245' type='radio' value='Yes'  id='choice_6_245_0'    \/>\n\t\t\t\t<label for='choice_6_245_0' id='label_6_245_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_245_1'>\n\t\t\t\t<input name='input_245' type='radio' value='No'  id='choice_6_245_1'    \/>\n\t\t\t\t<label for='choice_6_245_1' id='label_6_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_245_2'>\n\t\t\t\t<input name='input_245' type='radio' value='Ex-smoker'  id='choice_6_245_2'    \/>\n\t\t\t\t<label for='choice_6_245_2' id='label_6_245_2' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_246\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_246'><span class='gform-field-label__text'>How many cigarettes do you smoke per day?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_246' id='input_6_246' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you drink alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_247'>\n\t\t\t<li class='gchoice gchoice_6_247_0'>\n\t\t\t\t<input name='input_247' type='radio' value='Yes'  id='choice_6_247_0'    \/>\n\t\t\t\t<label for='choice_6_247_0' id='label_6_247_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_247_1'>\n\t\t\t\t<input name='input_247' type='radio' value='No'  id='choice_6_247_1'    \/>\n\t\t\t\t<label for='choice_6_247_1' id='label_6_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_250\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_250'><span class='gform-field-label__text'>The number of drinks - per day, week or month:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_250' id='input_6_250' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you take drugs?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_252'>\n\t\t\t<li class='gchoice gchoice_6_252_0'>\n\t\t\t\t<input name='input_252' type='radio' value='Yes'  id='choice_6_252_0'    \/>\n\t\t\t\t<label for='choice_6_252_0' id='label_6_252_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_252_1'>\n\t\t\t\t<input name='input_252' type='radio' value='No'  id='choice_6_252_1'    \/>\n\t\t\t\t<label for='choice_6_252_1' id='label_6_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_253\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you take methadone?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_253'>\n\t\t\t<li class='gchoice gchoice_6_253_0'>\n\t\t\t\t<input name='input_253' type='radio' value='Yes'  id='choice_6_253_0'    \/>\n\t\t\t\t<label for='choice_6_253_0' id='label_6_253_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_253_1'>\n\t\t\t\t<input name='input_253' type='radio' value='No'  id='choice_6_253_1'    \/>\n\t\t\t\t<label for='choice_6_253_1' id='label_6_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#58c6c3;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div>\n<\/li><li id=\"field_6_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Dental and medical history acceptance<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_6_88_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_88_1' ><span class='gform-field-label__text'>I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.<\/span><\/label><input type='hidden' name='input_88.2' value='I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_6_257\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acceptance of Collection, use, and disclosure of personal information<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_257.1' id='input_6_257_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_257_1' ><span class='gform-field-label__text'>I hereby give my consent to the collection, use and disclosure of my personal information by Clinique dentaire Le Blainvillier for the purpose of providing dental services.<\/span><\/label><input type='hidden' name='input_257.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by Clinique dentaire Le Blainvillier for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_257.3' value='2' class='gform_hidden' \/><\/div><\/li><li id=\"field_6_2\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'><span class='gform-field-label__text'>Signature of patient or parent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/li><li id=\"field_6_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_172'><span class='gform-field-label__text'>Print Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_6_172' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_33\" class=\"gfield gfield--type-text gfield--input-type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_33'><span class='gform-field-label__text'>Date<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_6_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_6' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_6' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_6' id='gform_theme_6' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_6' id='gform_style_settings_6' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='NNOBPX\/OtGdeCD08xIh3OF2bt8pqfPaoSU\/wMumpmesQKHPSdilw556FfCPcREXF2ULYiIdIYDw1ZxaEI8OXvzLf3XgKOLKvKnEDObXhig9SR5s=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>MEDICAL QUESTIONNAIRE<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"slim_seo":{"title":"Medical questionnaire - Clinique Dentaire \u00c9questre","description":"MEDICAL QUESTIONNAIRE Name This field is for validation purposes and should be left unchanged. YOUR INFORMATIONS * Veuillez porter attention First name * Last N"},"footnotes":""},"class_list":["post-49754","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/pages\/49754","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/comments?post=49754"}],"version-history":[{"count":5,"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/pages\/49754\/revisions"}],"predecessor-version":[{"id":49759,"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/pages\/49754\/revisions\/49759"}],"wp:attachment":[{"href":"https:\/\/cdequestre.com\/en\/wp-json\/wp\/v2\/media?parent=49754"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}