{"id":3856,"date":"2026-06-25T14:22:12","date_gmt":"2026-06-25T18:22:12","guid":{"rendered":"https:\/\/dentaireimplantocharleroi.com\/?page_id=3856"},"modified":"2026-06-26T09:14:33","modified_gmt":"2026-06-26T13:14:33","slug":"questionnaire-medical","status":"publish","type":"page","link":"https:\/\/dentaireimplantocharleroi.com\/en\/questionnaire-medical\/","title":{"rendered":"Medical questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3856\" class=\"elementor elementor-3856 elementor-3439\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4eb4c53 e-flex e-con-boxed tm-col-stretched-none tm-bg-color-over-image e-con e-parent\" data-id=\"4eb4c53\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-0003b27 e-con-full e-flex tm-col-stretched-none tm-bg-color-over-image e-con e-child\" data-id=\"0003b27\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-faab31e horizontal-line-align-left vertical-line-align-bottom elementor-widget elementor-widget-tm-ele-section-title\" data-id=\"faab31e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"tm-ele-section-title.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"tm-sc-section-title section-title \">\r\n\t<div class=\"title-wrapper\">\r\n\t\t\r\n\t\t\t\t\t<h5 class=\"title tm-split-text split-in-right\" >\r\n\r\n\t\t\r\n\t\t\t\t<span class=\"title-part1 \">New patient?<\/span>\r\n\t\t\r\n\t\t\t\t\t\t\t\r\n\t<\/h5>\r\n\t<div class=\"title-seperator-line\"><\/div>\t\t\t\t\t\t<\/div>\r\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-feb9964 elementor-widget elementor-widget-text-editor\" data-id=\"feb9964\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: left;\">Before your first appointment at the clinic, you must complete a form gathering details about your health status. To speed up the process, we invite you to fill out this form at home:<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ae52f82 e-con-full e-flex tm-col-stretched-none tm-bg-color-over-image e-con e-child\" data-id=\"ae52f82\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0d92f25 elementor-widget elementor-widget-shortcode\" data-id=\"0d92f25\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar 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class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_12_258\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_12_258' class='gfield_label gform-field-label' for='input_12_258'><span class='gform-field-label__text'>X\/Twitter<\/span><\/label><div class='ginput_container'><input name='input_258' id='input_12_258' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_12_258'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_12_41\" class=\"gfield gfield--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\" data-group-id=\"39a4d3c4\" data-field-span=\"12\"><div style=\"background-color:#f38165;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATIONS<\/div><\/div><div id=\"field_12_173\" class=\"gfield gfield--type-text rougerouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\" data-group-id=\"c5cd1f7a\" data-field-span=\"12\"><label id='gfield_label_12_173' class='gfield_label gform-field-label' for='input_12_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_12_173' type='text' value='* OUI * ' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_11\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"13b0f120\" data-field-span=\"12\"><label id='gfield_label_12_11' class='gfield_label gform-field-label' for='input_12_11'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_12_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_8\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0778e2f0\" data-field-span=\"12\"><label id='gfield_label_12_8' class='gfield_label gform-field-label' for='input_12_8'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_12_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_175\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"38afd075\" data-field-span=\"12\"><label id='gfield_label_12_175' class='gfield_label gform-field-label' for='input_12_175'><span class='gform-field-label__text'>Age<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_12_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_35\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"130d6dbe\" data-field-span=\"12\"><legend id='gfield_label_12_35' 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_text\">(Required)<\/span><\/span><\/legend><div id='input_12_35' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_12_35_2_container'><label for='input_12_35_2' id='input_12_35_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_12_35_2'   aria-required='true'   aria-labelledby=\"input_12_35_2_label gfield_label_12_35\" ><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_12_35_1_container'><label for='input_12_35_1' id='input_12_35_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_12_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_12_35_3_container'><label for='input_12_35_3' id='input_12_35_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_12_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><\/fieldset><fieldset id=\"field_12_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1861d075\" data-field-span=\"12\"><legend id='gfield_label_12_13' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_13'>\n\t\t\t<div class='gchoice gchoice_12_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='M'  id='choice_12_13_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_13_0 gfield_label_12_13\"   \/>\n\t\t\t\t\t<label for='choice_12_13_0' id='label_12_13_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='F'  id='choice_12_13_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_13_1' id='label_12_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Other'  id='choice_12_13_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_13_2' id='label_12_13_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_123\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"9a7d501a\" data-field-span=\"12\"><label id='gfield_label_12_123' class='gfield_label gform-field-label' for='input_12_123'><span class='gform-field-label__text'>Health Ins. No.<\/span><\/label><div class='gfield_description' id='gfield_description_12_123'>(To be completed for children aged 10 and under)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_12_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_12_123\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_254\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"0361084b\" data-field-span=\"12\"><label id='gfield_label_12_254' class='gfield_label gform-field-label' for='input_12_254'><span class='gform-field-label__text'>Expiration<\/span><\/label><div class='gfield_description' id='gfield_description_12_254'>(MM\/YYYY)<\/div><div class='ginput_container ginput_container_text'><input name='input_254' id='input_12_254' type='text' value='' class='medium'  aria-describedby=\"gfield_description_12_254\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_36\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"74210965\" data-field-span=\"12\"><label id='gfield_label_12_36' class='gfield_label gform-field-label' for='input_12_36'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_12_36' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_38\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"378bcbb8\" data-field-span=\"12\"><label id='gfield_label_12_38' class='gfield_label gform-field-label' for='input_12_38'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_12_38' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_37\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6388959e\" data-field-span=\"12\"><label id='gfield_label_12_37' class='gfield_label gform-field-label' for='input_12_37'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_12_37' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_12_34\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"79290fdd\" data-field-span=\"12\"><legend id='gfield_label_12_34' 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_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_12_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_12_34_1' value=''    aria-required='true'    aria-labelledby=\"input_12_34_1_label gfield_label_12_34\"\/>\n                                        <label for='input_12_34_1' id='input_12_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_12_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_12_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_12_34_3' id='input_12_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_12_34_4_container' >\n                                        <select name='input_34.4' id='input_12_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_12_34_4' id='input_12_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_12_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_12_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_12_34_5' id='input_12_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_12_34_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_12_126\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"48e4eb43\" data-field-span=\"12\"><legend id='gfield_label_12_126' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_126'>\n\t\t\t<div class='gchoice gchoice_12_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Yes'  id='choice_12_126_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_126_0 gfield_label_12_126\"   \/>\n\t\t\t\t\t<label for='choice_12_126_0' id='label_12_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='No'  id='choice_12_126_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_126_1' id='label_12_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_46\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"024e4f11\" data-field-span=\"12\"><label id='gfield_label_12_46' class='gfield_label gform-field-label' for='input_12_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_12_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_127\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6949cf2d\" data-field-span=\"12\"><label id='gfield_label_12_127' class='gfield_label gform-field-label' for='input_12_127'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_127' id='input_12_127' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_128\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cbf26bd4\" data-field-span=\"12\"><label id='gfield_label_12_128' class='gfield_label gform-field-label' for='input_12_128'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_12_128' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_129\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9d06cbfb\" data-field-span=\"12\"><label id='gfield_label_12_129' class='gfield_label gform-field-label' for='input_12_129'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_12_129' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_130\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b03034dd\" data-field-span=\"12\"><label id='gfield_label_12_130' class='gfield_label gform-field-label' for='input_12_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_12_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_133\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0ca7e021\" data-field-span=\"12\"><label id='gfield_label_12_133' class='gfield_label gform-field-label' for='input_12_133'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_133' id='input_12_133' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_132\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"430f7ac6\" data-field-span=\"12\"><label id='gfield_label_12_132' class='gfield_label gform-field-label' for='input_12_132'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_12_132' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_131\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cfe77f4b\" data-field-span=\"12\"><label id='gfield_label_12_131' class='gfield_label gform-field-label' for='input_12_131'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_12_131' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_12_134\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"4dc147a1\" data-field-span=\"12\"><legend id='gfield_label_12_134' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_134'>\n\t\t\t<div class='gchoice gchoice_12_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Father'  id='choice_12_134_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_134_0 gfield_label_12_134\"   \/>\n\t\t\t\t\t<label for='choice_12_134_0' id='label_12_134_0' class='gform-field-label gform-field-label--type-inline'>Father<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Mother'  id='choice_12_134_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_134_1' id='label_12_134_1' class='gform-field-label gform-field-label--type-inline'>Mother<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_134_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Other'  id='choice_12_134_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_134_2' id='label_12_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_47\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"fda2a033\" data-field-span=\"12\"><label id='gfield_label_12_47' class='gfield_label gform-field-label' for='input_12_47'><span class='gform-field-label__text'>Specify Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_12_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_40\" class=\"gfield gfield--type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f70fd005\" data-field-span=\"12\"><label id='gfield_label_12_40' class='gfield_label gform-field-label' for='input_12_40'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_12_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_12_179\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"86590b61\" data-field-span=\"12\"><legend id='gfield_label_12_179' 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_text\">(Required)<\/span><\/span><\/legend><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_12_179'>\n                            \n                            <span id='input_12_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_12_179_3' value=''   aria-required='true'     aria-labelledby=\"input_12_179_3_label gfield_label_12_179\"\/>\n                                                    <label for='input_12_179_3' id='input_12_179_3_label' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            <span id='input_12_179_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.4' id='input_12_179_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_179_4' id='input_12_179_4_label' class='gform-field-label gform-field-label--type-sub '>Relationship to patient<\/label>\n                                                <\/span>\n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_12_180\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"c62d10a3\" data-field-span=\"12\"><label id='gfield_label_12_180' class='gfield_label gform-field-label' for='input_12_180'><span class='gform-field-label__text'>Main Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_180' id='input_12_180' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_181\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"aecc8d17\" data-field-span=\"12\"><label id='gfield_label_12_181' class='gfield_label gform-field-label' for='input_12_181'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_181' id='input_12_181' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_42\" class=\"gfield gfield--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\" data-group-id=\"bb1459c9\" data-field-span=\"12\"><br><br><div style=\"background-color:#f38165;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL INFORMATION<\/div><\/div><div id=\"field_12_139\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"57296918\" data-field-span=\"12\"><label id='gfield_label_12_139' class='gfield_label gform-field-label' for='input_12_139'><span class='gform-field-label__text'>Reason for today\u2019s visit<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_12_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_15\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"00e63a68\" data-field-span=\"12\"><legend id='gfield_label_12_15' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_15'>\n\t\t\t<div class='gchoice gchoice_12_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='0-6 month'  id='choice_12_15_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_15_0 gfield_label_12_15\"   \/>\n\t\t\t\t\t<label for='choice_12_15_0' id='label_12_15_0' class='gform-field-label gform-field-label--type-inline'>0-6 month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='6-12 month'  id='choice_12_15_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_15_1' id='label_12_15_1' class='gform-field-label gform-field-label--type-inline'>6-12 month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='+12 month'  id='choice_12_15_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_15_2' id='label_12_15_2' class='gform-field-label gform-field-label--type-inline'>+12 month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_182\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9c3e78de\" data-field-span=\"12\"><label id='gfield_label_12_182' class='gfield_label gform-field-label' for='input_12_182'><span class='gform-field-label__text'>Treatment(s) received<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_12_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_142\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"6ce70e81\" data-field-span=\"12\"><legend id='gfield_label_12_142' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_142'>\n\t\t\t<div class='gchoice gchoice_12_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_12_142_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_142_0 gfield_label_12_142\"   \/>\n\t\t\t\t\t<label for='choice_12_142_0' id='label_12_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_12_142_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_142_1' id='label_12_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_143\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"304864e2\" data-field-span=\"12\"><legend id='gfield_label_12_143' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_143'>\n\t\t\t<div class='gchoice gchoice_12_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='Yes'  id='choice_12_143_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_143_0 gfield_label_12_143\"   \/>\n\t\t\t\t\t<label for='choice_12_143_0' id='label_12_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='No'  id='choice_12_143_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_143_1' id='label_12_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_145\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"2dc68327\" data-field-span=\"12\"><legend id='gfield_label_12_145' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_145'>\n\t\t\t<div class='gchoice gchoice_12_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Not at all'  id='choice_12_145_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_145_0 gfield_label_12_145\"   \/>\n\t\t\t\t\t<label for='choice_12_145_0' id='label_12_145_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='A little'  id='choice_12_145_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_145_1' id='label_12_145_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_145_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Very much'  id='choice_12_145_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_145_2' id='label_12_145_2' class='gform-field-label gform-field-label--type-inline'>Very much<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_136\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"db0ea929\" data-field-span=\"12\"><label id='gfield_label_12_136' class='gfield_label gform-field-label' for='input_12_136'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_12_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_183\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"c2612e96\" data-field-span=\"12\"><legend id='gfield_label_12_183' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_183'>\n\t\t\t<div class='gchoice gchoice_12_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Yes'  id='choice_12_183_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_183_0 gfield_label_12_183\"   \/>\n\t\t\t\t\t<label for='choice_12_183_0' id='label_12_183_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='No'  id='choice_12_183_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_183_1' id='label_12_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_184\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"10e5bb5c\" data-field-span=\"12\"><label id='gfield_label_12_184' class='gfield_label gform-field-label' for='input_12_184'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_12_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_185\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"f938d7e9\" data-field-span=\"12\"><legend id='gfield_label_12_185' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_185'>\n\t\t\t<div class='gchoice gchoice_12_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Yes'  id='choice_12_185_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_185_0 gfield_label_12_185\"   \/>\n\t\t\t\t\t<label for='choice_12_185_0' id='label_12_185_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='No'  id='choice_12_185_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_185_1' id='label_12_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_186\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a2f6398f\" data-field-span=\"12\"><label id='gfield_label_12_186' class='gfield_label gform-field-label' for='input_12_186'><span class='gform-field-label__text'>Physician&#039;s Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_12_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_256\" class=\"gfield gfield--type-phone gfield--phone-format-standard gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bb3c7cda\" data-field-span=\"12\"><label id='gfield_label_12_256' class='gfield_label gform-field-label' for='input_12_256'><span class='gform-field-label__text'>Physician Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_256' id='input_12_256' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_12_255\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e8273475\" data-field-span=\"12\"><label id='gfield_label_12_255' class='gfield_label gform-field-label' for='input_12_255'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_12_255' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_187\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"d544be4d\" data-field-span=\"12\"><legend id='gfield_label_12_187' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_187'>\n\t\t\t<div class='gchoice gchoice_12_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='Yes'  id='choice_12_187_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_187_0 gfield_label_12_187\"   \/>\n\t\t\t\t\t<label for='choice_12_187_0' id='label_12_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_187_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='No'  id='choice_12_187_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_187_1' id='label_12_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_188\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"c8a95151\" data-field-span=\"12\"><label id='gfield_label_12_188' class='gfield_label gform-field-label' for='input_12_188'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_12_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_189\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"430d7fe1\" data-field-span=\"12\"><legend id='gfield_label_12_189' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_189'>\n\t\t\t<div class='gchoice gchoice_12_189_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='Yes'  id='choice_12_189_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_189_0 gfield_label_12_189\"   \/>\n\t\t\t\t\t<label for='choice_12_189_0' id='label_12_189_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_189_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='No'  id='choice_12_189_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_189_1' id='label_12_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_190\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"792cedc9\" data-field-span=\"12\"><label id='gfield_label_12_190' class='gfield_label gform-field-label' for='input_12_190'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_12_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_191\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"b3297edd\" data-field-span=\"12\"><legend id='gfield_label_12_191' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_191'>\n\t\t\t<div class='gchoice gchoice_12_191_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_191' type='radio' value='Yes'  id='choice_12_191_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_191_0 gfield_label_12_191\"   \/>\n\t\t\t\t\t<label for='choice_12_191_0' id='label_12_191_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_191_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_191' type='radio' value='No'  id='choice_12_191_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_191_1' id='label_12_191_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_192\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"dafe86d3\" data-field-span=\"12\"><label id='gfield_label_12_192' class='gfield_label gform-field-label' for='input_12_192'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_12_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_193\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"af474f48\" data-field-span=\"12\"><legend id='gfield_label_12_193' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_193'>\n\t\t\t<div class='gchoice gchoice_12_193_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='Yes'  id='choice_12_193_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_193_0 gfield_label_12_193\"   \/>\n\t\t\t\t\t<label for='choice_12_193_0' id='label_12_193_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_193_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='No'  id='choice_12_193_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_193_1' id='label_12_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_194\" class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a6d9e6c7\" data-field-span=\"12\"><label id='gfield_label_12_194' class='gfield_label gform-field-label' for='input_12_194'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_12_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_195\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"42a2cf7e\" data-field-span=\"12\"><legend id='gfield_label_12_195' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_195'>\n\t\t\t<div class='gchoice gchoice_12_195_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='Yes'  id='choice_12_195_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_195_0 gfield_label_12_195\"   \/>\n\t\t\t\t\t<label for='choice_12_195_0' id='label_12_195_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_195_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='No'  id='choice_12_195_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_195_1' id='label_12_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_196\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"ad96ca61\" data-field-span=\"12\"><legend id='gfield_label_12_196' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_196'>\n\t\t\t<div class='gchoice gchoice_12_196_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='Yes'  id='choice_12_196_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_196_0 gfield_label_12_196\"   \/>\n\t\t\t\t\t<label for='choice_12_196_0' id='label_12_196_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_196_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='No'  id='choice_12_196_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_196_1' id='label_12_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_197\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"ac20713d\" data-field-span=\"12\"><legend id='gfield_label_12_197' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_197'>\n\t\t\t<div class='gchoice gchoice_12_197_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='Yes'  id='choice_12_197_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_197_0 gfield_label_12_197\"   \/>\n\t\t\t\t\t<label for='choice_12_197_0' id='label_12_197_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_197_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='No'  id='choice_12_197_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_197_1' id='label_12_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_198\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7e820637\" data-field-span=\"12\"><legend id='gfield_label_12_198' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_198'>\n\t\t\t<div class='gchoice gchoice_12_198_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes birth control'  id='choice_12_198_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_198_0 gfield_label_12_198\"   \/>\n\t\t\t\t\t<label for='choice_12_198_0' id='label_12_198_0' class='gform-field-label gform-field-label--type-inline'>Yes birth control<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_198_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes hormones'  id='choice_12_198_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_198_1' id='label_12_198_1' class='gform-field-label gform-field-label--type-inline'>Yes hormones<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_198_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='No'  id='choice_12_198_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_198_2' id='label_12_198_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_199\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f24f196e\" data-field-span=\"12\"><label id='gfield_label_12_199' class='gfield_label gform-field-label' for='input_12_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_12_199' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_138\" class=\"gfield gfield--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\" data-group-id=\"c9fa9c2e\" data-field-span=\"12\"><br><br><div style=\"background-color:#f38165;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR CURRENT CONDITION<\/div><\/div><div id=\"field_12_167\" class=\"gfield gfield--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\" data-group-id=\"4a073c43\" data-field-span=\"12\"><div style=\"background-color:#ffffff;color:#f38165;font-weight:bold;font-size:16px;\">Blood disorders<\/div><\/div><fieldset id=\"field_12_55\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"c58bdfce\" data-field-span=\"12\"><legend id='gfield_label_12_55' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_55'>\n\t\t\t<div class='gchoice gchoice_12_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_12_55_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_55_0 gfield_label_12_55\"   \/>\n\t\t\t\t\t<label for='choice_12_55_0' id='label_12_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_12_55_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_55_1' id='label_12_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_201\" class=\"gfield gfield--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\" data-group-id=\"3ced0a6b\" data-field-span=\"12\"><div style=\"background-color:#ffffff;color:#f38165;font-weight:bold;font-size:16px;\">Heart conditions<\/div><\/div><fieldset id=\"field_12_54\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7c507bf7\" data-field-span=\"12\"><legend id='gfield_label_12_54' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_54'>\n\t\t\t<div class='gchoice gchoice_12_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_12_54_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_54_0 gfield_label_12_54\"   \/>\n\t\t\t\t\t<label for='choice_12_54_0' id='label_12_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_12_54_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_54_1' id='label_12_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_202\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"e6c03ed0\" data-field-span=\"12\"><legend id='gfield_label_12_202' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_202'>\n\t\t\t<div class='gchoice gchoice_12_202_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='Yes'  id='choice_12_202_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_202_0 gfield_label_12_202\"   \/>\n\t\t\t\t\t<label for='choice_12_202_0' id='label_12_202_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_202_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='No'  id='choice_12_202_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_202_1' id='label_12_202_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_203\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"854584e8\" data-field-span=\"12\"><legend id='gfield_label_12_203' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_203'>\n\t\t\t<div class='gchoice gchoice_12_203_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='Yes'  id='choice_12_203_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_203_0 gfield_label_12_203\"   \/>\n\t\t\t\t\t<label for='choice_12_203_0' id='label_12_203_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_203_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='No'  id='choice_12_203_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_203_1' id='label_12_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_204\" class=\"gfield gfield--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\" data-group-id=\"38aa908f\" data-field-span=\"12\"><div style=\"background-color:#ffffff;color:#f38165;font-weight:bold;font-size:16px;\">Other<\/div><\/div><fieldset id=\"field_12_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"cf450386\" data-field-span=\"12\"><legend id='gfield_label_12_57' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_57'>\n\t\t\t<div class='gchoice gchoice_12_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes - Low'  id='choice_12_57_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_57_0 gfield_label_12_57\"   \/>\n\t\t\t\t\t<label for='choice_12_57_0' id='label_12_57_0' class='gform-field-label gform-field-label--type-inline'>Yes - Low<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes - High'  id='choice_12_57_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_57_1' id='label_12_57_1' class='gform-field-label gform-field-label--type-inline'>Yes - High<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_12_57_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_57_2' id='label_12_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_205\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"e107df5b\" data-field-span=\"12\"><legend id='gfield_label_12_205' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_205'>\n\t\t\t<div class='gchoice gchoice_12_205_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='Yes'  id='choice_12_205_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_205_0 gfield_label_12_205\"   \/>\n\t\t\t\t\t<label for='choice_12_205_0' id='label_12_205_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_205_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='No'  id='choice_12_205_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_205_1' id='label_12_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_206\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"40a946d0\" data-field-span=\"12\"><legend id='gfield_label_12_206' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_206'>\n\t\t\t<div class='gchoice gchoice_12_206_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='Yes'  id='choice_12_206_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_206_0 gfield_label_12_206\"   \/>\n\t\t\t\t\t<label for='choice_12_206_0' id='label_12_206_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_206_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='No'  id='choice_12_206_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_206_1' id='label_12_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_207\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"227aa75b\" data-field-span=\"12\"><legend id='gfield_label_12_207' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_207'>\n\t\t\t<div class='gchoice gchoice_12_207_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Yes'  id='choice_12_207_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_207_0 gfield_label_12_207\"   \/>\n\t\t\t\t\t<label for='choice_12_207_0' id='label_12_207_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_207_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='No'  id='choice_12_207_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_207_1' id='label_12_207_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_208\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"ca043688\" data-field-span=\"12\"><legend id='gfield_label_12_208' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_208'>\n\t\t\t<div class='gchoice gchoice_12_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='Yes'  id='choice_12_208_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_208_0 gfield_label_12_208\"   \/>\n\t\t\t\t\t<label for='choice_12_208_0' id='label_12_208_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_208_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='No'  id='choice_12_208_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_208_1' id='label_12_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_209\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"1d2da107\" data-field-span=\"12\"><legend id='gfield_label_12_209' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_209'>\n\t\t\t<div class='gchoice gchoice_12_209_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Yes'  id='choice_12_209_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_209_0 gfield_label_12_209\"   \/>\n\t\t\t\t\t<label for='choice_12_209_0' id='label_12_209_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_209_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='No'  id='choice_12_209_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_209_1' id='label_12_209_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_210\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cbd72c22\" data-field-span=\"12\"><label id='gfield_label_12_210' class='gfield_label gform-field-label' for='input_12_210'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_12_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_211\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"2ab3ec4d\" data-field-span=\"12\"><legend id='gfield_label_12_211' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_211'>\n\t\t\t<div class='gchoice gchoice_12_211_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='Yes, Ulcer'  id='choice_12_211_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_211_0 gfield_label_12_211\"   \/>\n\t\t\t\t\t<label for='choice_12_211_0' id='label_12_211_0' class='gform-field-label gform-field-label--type-inline'>Yes, Ulcer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_211_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='Yes, Reflux'  id='choice_12_211_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_211_1' id='label_12_211_1' class='gform-field-label gform-field-label--type-inline'>Yes, Reflux<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_211_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='No'  id='choice_12_211_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_211_2' id='label_12_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_212\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"29944b2e\" data-field-span=\"12\"><legend id='gfield_label_12_212' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_212'>\n\t\t\t<div class='gchoice gchoice_12_212_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='Yes'  id='choice_12_212_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_212_0 gfield_label_12_212\"   \/>\n\t\t\t\t\t<label for='choice_12_212_0' id='label_12_212_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_212_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='No'  id='choice_12_212_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_212_1' id='label_12_212_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_213\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"98bd5092\" data-field-span=\"12\"><legend id='gfield_label_12_213' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Diabetes<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_213'>\n\t\t\t<div class='gchoice gchoice_12_213_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='Yes'  id='choice_12_213_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_213_0 gfield_label_12_213\"   \/>\n\t\t\t\t\t<label for='choice_12_213_0' id='label_12_213_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_213_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='No'  id='choice_12_213_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_213_1' id='label_12_213_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_214\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"e9cd5d7e\" data-field-span=\"12\"><legend id='gfield_label_12_214' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_214'>\n\t\t\t<div class='gchoice gchoice_12_214_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='Yes'  id='choice_12_214_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_214_0 gfield_label_12_214\"   \/>\n\t\t\t\t\t<label for='choice_12_214_0' id='label_12_214_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_214_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='No'  id='choice_12_214_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_214_1' id='label_12_214_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_217\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"e6aee772\" data-field-span=\"12\"><legend id='gfield_label_12_217' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_217'>\n\t\t\t<div class='gchoice gchoice_12_217_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_217' type='radio' value='Yes'  id='choice_12_217_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_217_0 gfield_label_12_217\"   \/>\n\t\t\t\t\t<label for='choice_12_217_0' id='label_12_217_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_217_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_217' type='radio' value='No'  id='choice_12_217_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_217_1' id='label_12_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_218\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"47ec0cf0\" data-field-span=\"12\"><label id='gfield_label_12_218' class='gfield_label gform-field-label' for='input_12_218'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_12_218' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_219\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"a1acf268\" data-field-span=\"12\"><legend id='gfield_label_12_219' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Radiotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_219'>\n\t\t\t<div class='gchoice gchoice_12_219_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='Yes'  id='choice_12_219_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_219_0 gfield_label_12_219\"   \/>\n\t\t\t\t\t<label for='choice_12_219_0' id='label_12_219_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_219_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='No'  id='choice_12_219_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_219_1' id='label_12_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_220\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"50f08ba7\" data-field-span=\"12\"><legend id='gfield_label_12_220' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chemotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_220'>\n\t\t\t<div class='gchoice gchoice_12_220_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='Yes'  id='choice_12_220_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_220_0 gfield_label_12_220\"   \/>\n\t\t\t\t\t<label for='choice_12_220_0' id='label_12_220_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_220_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='No'  id='choice_12_220_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_220_1' id='label_12_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_221\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"fb3cdfe8\" data-field-span=\"12\"><legend id='gfield_label_12_221' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_221'>\n\t\t\t<div class='gchoice gchoice_12_221_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='Yes'  id='choice_12_221_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_221_0 gfield_label_12_221\"   \/>\n\t\t\t\t\t<label for='choice_12_221_0' id='label_12_221_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_221_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='No'  id='choice_12_221_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_221_1' id='label_12_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_222\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"5458f0ff\" data-field-span=\"12\"><legend id='gfield_label_12_222' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_222'>\n\t\t\t<div class='gchoice gchoice_12_222_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_222' type='radio' value='Yes'  id='choice_12_222_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_222_0 gfield_label_12_222\"   \/>\n\t\t\t\t\t<label for='choice_12_222_0' id='label_12_222_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_222_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_222' type='radio' value='No'  id='choice_12_222_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_222_1' id='label_12_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_223\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d6174739\" data-field-span=\"12\"><label id='gfield_label_12_223' class='gfield_label gform-field-label' for='input_12_223'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_12_223' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_224\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1ebca6b1\" data-field-span=\"12\"><legend id='gfield_label_12_224' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_224'>\n\t\t\t<div class='gchoice gchoice_12_224_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_224' type='radio' value='Yes'  id='choice_12_224_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_224_0 gfield_label_12_224\"   \/>\n\t\t\t\t\t<label for='choice_12_224_0' id='label_12_224_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_224_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_224' type='radio' value='No'  id='choice_12_224_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_224_1' id='label_12_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_225\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"9916b52a\" data-field-span=\"12\"><legend id='gfield_label_12_225' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_225'>\n\t\t\t<div class='gchoice gchoice_12_225_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='Yes'  id='choice_12_225_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_225_0 gfield_label_12_225\"   \/>\n\t\t\t\t\t<label for='choice_12_225_0' id='label_12_225_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_225_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='No'  id='choice_12_225_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_225_1' id='label_12_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_226\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"f81dc035\" data-field-span=\"12\"><legend id='gfield_label_12_226' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Earaches<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_226'>\n\t\t\t<div class='gchoice gchoice_12_226_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_226' type='radio' value='Yes'  id='choice_12_226_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_226_0 gfield_label_12_226\"   \/>\n\t\t\t\t\t<label for='choice_12_226_0' id='label_12_226_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_226_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_226' type='radio' value='No'  id='choice_12_226_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_226_1' id='label_12_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_227\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"4cc57693\" data-field-span=\"12\"><legend id='gfield_label_12_227' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Arthritis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_227'>\n\t\t\t<div class='gchoice gchoice_12_227_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_227' type='radio' value='Yes'  id='choice_12_227_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_227_0 gfield_label_12_227\"   \/>\n\t\t\t\t\t<label for='choice_12_227_0' id='label_12_227_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_227_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_227' type='radio' value='No'  id='choice_12_227_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_227_1' id='label_12_227_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_231\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7afb15a5\" data-field-span=\"12\"><legend id='gfield_label_12_231' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_231'>\n\t\t\t<div class='gchoice gchoice_12_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='Yes'  id='choice_12_231_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_231_0 gfield_label_12_231\"   \/>\n\t\t\t\t\t<label for='choice_12_231_0' id='label_12_231_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='No'  id='choice_12_231_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_231_1' id='label_12_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_232\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1a352b3c\" data-field-span=\"12\"><legend id='gfield_label_12_232' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Epilepsy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_232'>\n\t\t\t<div class='gchoice gchoice_12_232_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='Yes'  id='choice_12_232_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_232_0 gfield_label_12_232\"   \/>\n\t\t\t\t\t<label for='choice_12_232_0' id='label_12_232_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_232_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='No'  id='choice_12_232_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_232_1' id='label_12_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_235\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"8173a279\" data-field-span=\"12\"><legend id='gfield_label_12_235' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_235'>\n\t\t\t<div class='gchoice gchoice_12_235_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='Yes'  id='choice_12_235_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_235_0 gfield_label_12_235\"   \/>\n\t\t\t\t\t<label for='choice_12_235_0' id='label_12_235_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_235_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='No'  id='choice_12_235_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_235_1' id='label_12_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_237\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"1c37d15d\" data-field-span=\"12\"><legend id='gfield_label_12_237' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Asthma<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_237'>\n\t\t\t<div class='gchoice gchoice_12_237_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_237' type='radio' value='Yes'  id='choice_12_237_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_237_0 gfield_label_12_237\"   \/>\n\t\t\t\t\t<label for='choice_12_237_0' id='label_12_237_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_237_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_237' type='radio' value='No'  id='choice_12_237_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_237_1' id='label_12_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_238\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"6bccb9e9\" data-field-span=\"12\"><legend id='gfield_label_12_238' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_238'>\n\t\t\t<div class='gchoice gchoice_12_238_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='Yes'  id='choice_12_238_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_238_0 gfield_label_12_238\"   \/>\n\t\t\t\t\t<label for='choice_12_238_0' id='label_12_238_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_238_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='No'  id='choice_12_238_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_238_1' id='label_12_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_236\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"78096148\" data-field-span=\"12\"><legend id='gfield_label_12_236' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_236'>\n\t\t\t<div class='gchoice gchoice_12_236_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='Yes'  id='choice_12_236_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_236_0 gfield_label_12_236\"   \/>\n\t\t\t\t\t<label for='choice_12_236_0' id='label_12_236_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_236_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='No'  id='choice_12_236_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_236_1' id='label_12_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_233\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"80f9fab8\" data-field-span=\"12\"><legend id='gfield_label_12_233' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_233'>\n\t\t\t<div class='gchoice gchoice_12_233_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Yes'  id='choice_12_233_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_233_0 gfield_label_12_233\"   \/>\n\t\t\t\t\t<label for='choice_12_233_0' id='label_12_233_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_233_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='No'  id='choice_12_233_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_233_1' id='label_12_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_234\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"39535928\" data-field-span=\"12\"><legend id='gfield_label_12_234' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_234'>\n\t\t\t<div class='gchoice gchoice_12_234_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='Yes'  id='choice_12_234_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_234_0 gfield_label_12_234\"   \/>\n\t\t\t\t\t<label for='choice_12_234_0' id='label_12_234_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_234_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='No'  id='choice_12_234_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_234_1' id='label_12_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_228\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"d3093619\" data-field-span=\"12\"><legend id='gfield_label_12_228' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Osteoporosis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_228'>\n\t\t\t<div class='gchoice gchoice_12_228_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='Yes'  id='choice_12_228_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_228_0 gfield_label_12_228\"   \/>\n\t\t\t\t\t<label for='choice_12_228_0' id='label_12_228_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_228_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='No'  id='choice_12_228_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_228_1' id='label_12_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_230\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"6a119229\" data-field-span=\"12\"><legend id='gfield_label_12_230' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_230'>\n\t\t\t<div class='gchoice gchoice_12_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Yes'  id='choice_12_230_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_230_0 gfield_label_12_230\"   \/>\n\t\t\t\t\t<label for='choice_12_230_0' id='label_12_230_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='No'  id='choice_12_230_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_230_1' id='label_12_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_229\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"cf4b274f\" data-field-span=\"12\"><legend id='gfield_label_12_229' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_229'>\n\t\t\t<div class='gchoice gchoice_12_229_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='Yes'  id='choice_12_229_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_229_0 gfield_label_12_229\"   \/>\n\t\t\t\t\t<label for='choice_12_229_0' id='label_12_229_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_229_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='No'  id='choice_12_229_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_229_1' id='label_12_229_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_240\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7ef76e2a\" data-field-span=\"12\"><legend id='gfield_label_12_240' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Allergy or manifestation with products containing:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_240'><div class='gchoice gchoice_12_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_12_240_1'    aria-labelledby=\"label_12_240_1 gfield_label_12_240\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_1' id='label_12_240_1' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_2'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_2' id='label_12_240_2' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_3'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_3' id='label_12_240_3' class='gform-field-label gform-field-label--type-inline'>Other antibiotics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_4'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_4' id='label_12_240_4' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_5'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_5' id='label_12_240_5' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_6'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_6' id='label_12_240_6' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_7'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_7' id='label_12_240_7' class='gform-field-label gform-field-label--type-inline'>Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_8'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_8' id='label_12_240_8' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_9'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_9' id='label_12_240_9' class='gform-field-label gform-field-label--type-inline'>Iodine-containing products<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_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_12_240_11'    \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_240_11' id='label_12_240_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_241\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f160fb46\" data-field-span=\"12\"><label id='gfield_label_12_241' class='gfield_label gform-field-label' for='input_12_241'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_12_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_120\" class=\"gfield gfield--type-textarea gf_left field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\" data-group-id=\"19127d90\" data-field-span=\"12\"><label id='gfield_label_12_120' class='gfield_label gform-field-label' for='input_12_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_12_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_242\" class=\"gfield gfield--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\" data-group-id=\"51d6c81c\" data-field-span=\"12\"><br><div style=\"background-color:#ffffff;color:#f38165;font-weight:bold;font-size:16px;\">Other aspects<\/div><\/div><fieldset id=\"field_12_243\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"de75c1bf\" data-field-span=\"12\"><legend id='gfield_label_12_243' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_243'>\n\t\t\t<div class='gchoice gchoice_12_243_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='Yes'  id='choice_12_243_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_243_0 gfield_label_12_243\"   \/>\n\t\t\t\t\t<label for='choice_12_243_0' id='label_12_243_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_243_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='No'  id='choice_12_243_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_243_1' id='label_12_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_244\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"5bae3dae\" data-field-span=\"12\"><legend id='gfield_label_12_244' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_244'>\n\t\t\t<div class='gchoice gchoice_12_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='Yes'  id='choice_12_244_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_244_0 gfield_label_12_244\"   \/>\n\t\t\t\t\t<label for='choice_12_244_0' id='label_12_244_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='No'  id='choice_12_244_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_244_1' id='label_12_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_245\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"a929e834\" data-field-span=\"12\"><legend id='gfield_label_12_245' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_245'>\n\t\t\t<div class='gchoice gchoice_12_245_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Yes'  id='choice_12_245_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_245_0 gfield_label_12_245\"   \/>\n\t\t\t\t\t<label for='choice_12_245_0' id='label_12_245_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_245_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='No'  id='choice_12_245_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_245_1' id='label_12_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_245_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Ex-smoker'  id='choice_12_245_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_245_2' id='label_12_245_2' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_246\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2ba4774c\" data-field-span=\"12\"><label id='gfield_label_12_246' class='gfield_label gform-field-label' for='input_12_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_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_246' id='input_12_246' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_247\" class=\"gfield gfield--type-radio gfield--type-choice 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\" data-group-id=\"5122af2e\" data-field-span=\"12\"><legend id='gfield_label_12_247' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_247'>\n\t\t\t<div class='gchoice gchoice_12_247_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='Yes'  id='choice_12_247_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_247_0 gfield_label_12_247\"   \/>\n\t\t\t\t\t<label for='choice_12_247_0' id='label_12_247_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_247_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='No'  id='choice_12_247_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_247_1' id='label_12_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_250\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"8d494eee\" data-field-span=\"12\"><label id='gfield_label_12_250' class='gfield_label gform-field-label' for='input_12_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_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_250' id='input_12_250' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_252\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"dff8898f\" data-field-span=\"12\"><legend id='gfield_label_12_252' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_252'>\n\t\t\t<div class='gchoice gchoice_12_252_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='Yes'  id='choice_12_252_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_252_0 gfield_label_12_252\"   \/>\n\t\t\t\t\t<label for='choice_12_252_0' id='label_12_252_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_252_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='No'  id='choice_12_252_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_252_1' id='label_12_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_253\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"f90552be\" data-field-span=\"12\"><legend id='gfield_label_12_253' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_253'>\n\t\t\t<div class='gchoice gchoice_12_253_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='Yes'  id='choice_12_253_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_12_253_0 gfield_label_12_253\"   \/>\n\t\t\t\t\t<label for='choice_12_253_0' id='label_12_253_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_253_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='No'  id='choice_12_253_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_12_253_1' id='label_12_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_91\" class=\"gfield gfield--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\" data-group-id=\"83f852f1\" data-field-span=\"12\"><div style=\"background-color:#f38165;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div>\n<br><br><strong>Please consult the following documents before your acceptance and signature:<\/strong><br><br>\n\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGConsentementpatientmoins14ans-eng.pdf\" target=\"_blank\"><strong>Consentement - Patient 14 ans et moins<\/strong><\/a><br>\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGConsentementpatientplus14ans-eng.pdf\" target=\"_blank\"><strong>Consentement - Patient 14 ans et plus<\/strong><\/a><br>\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGPolitiqudeconfidentialite-eng.pdf\" target=\"_blank\"><strong>Politique de confidentialit\u00e9<\/strong><\/a><br><\/div><fieldset id=\"field_12_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"7b4197e6\" data-field-span=\"12\"><legend id='gfield_label_12_88' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_12_88_1' type='checkbox' value='1'   aria-labelledby=\"input_12_88_1_label gfield_label_12_88\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label id='input_12_88_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_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><\/fieldset><fieldset id=\"field_12_257\" class=\"gfield gfield--type-consent gfield--type-choice 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\" data-group-id=\"a67d928b\" data-field-span=\"12\"><legend id='gfield_label_12_257' 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_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_257.1' id='input_12_257_1' type='checkbox' value='1'   aria-labelledby=\"input_12_257_1_label gfield_label_12_257\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label id='input_12_257_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_257_1' ><span class='gform-field-label__text'>I hereby give my consent to the collection, use and disclosure of my personal information by Soins Dentaire C\u00f4t\u00e9 Gilbert 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 Soins Dentaire C\u00f4t\u00e9 Gilbert for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_257.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_12_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"dfe2912c\" data-field-span=\"12\"><legend id='gfield_label_12_2' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Signature of patient or parent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_2' id='input_12_2_signature_filename' class='gfield_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_12_2_Container' class='gfield_signature_container' style='height:90px; width:600px; ' ><input type='hidden' id='input_12_2_data' name='input_12_2_data' class='gfield_signature_data' \/><canvas id=\"input_12_2\" width=\"600\" height=\"90\" style=\"border-style: solid; border-width: 1px; border-color: #f7977a; background-color:#ebebeb; cursor: url(https:\/\/dentaireimplantocharleroi.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><input type='text' id='input_12_2_textinput' name='input_12_2_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:600px;height:90px;border-style:solid;border-width:1px;border-color:#f7977a;background-color:#ebebeb;font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#003370;' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' \/><style type='text\/css'>\n                #input_12_2_textinput::placeholder {\n                    font-size: 1.5rem;\n                    font-family: Arial;\n                    opacity: 0.8;\n                }\n            <\/style><\/div><div id='input_12_2_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:600px;max-width:100%;display:flex;align-items:center;'><div id='input_12_2_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0;'><\/div><input type='hidden' id='input_12_2_font_select' class='gfield_signature_font_select' value='script' \/><div id='input_12_2_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'><\/span><button type='button' id='input_12_2_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:\"Snell Roundhand\", \"Segoe Script\", cursive;color:#003370'>Your Name<\/button><ul id='input_12_2_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box;'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive; color:#003370' aria-label='Your Name, Script style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;, &quot;Comic Sans MS&quot;, cursive; color:#003370' aria-label='Your Name, Handwritten style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;, &quot;Segoe Print&quot;, cursive; color:#003370' aria-label='Your Name, Print style'>Your Name<\/li><\/ul><\/div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center;'><button type='button' id='input_12_2_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Text Signature' aria-label='Text Signature'><\/button><button type='button' id='input_12_2_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Draw Signature' aria-label='Draw Signature'><\/button><button type='button' id='input_12_2_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Clear Signature' aria-label='Clear Signature'><\/button><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_12_172\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6726abe3\" data-field-span=\"12\"><label id='gfield_label_12_172' class='gfield_label gform-field-label' for='input_12_172'><span class='gform-field-label__text'>Print Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_12_172' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f09904c9\" data-field-span=\"12\"><label id='gfield_label_12_33' class='gfield_label gform-field-label' for='input_12_33'><span class='gform-field-label__text'>Date<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_12_33' type='text' value='23 octobre 2026 00h38' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_12' 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_12' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_12' id='gform_theme_12' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_12' id='gform_style_settings_12' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_12' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='12' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='HncZ6fsj\/UZFPkxwmvT8BFyXSuXBHno+pxpYVxMAac+Oyr77u6wvj8y46+8Bs+ZEvfzPx8Ca9StcFg4aMS0xXkiqMBR1ZvCiSdJRO93Nee\/Nhe0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' 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