{"id":57,"date":"2020-06-02T09:38:21","date_gmt":"2020-06-02T13:38:21","guid":{"rendered":"https:\/\/parodontierockland.com\/qm-en\/?page_id=57"},"modified":"2022-01-14T16:19:00","modified_gmt":"2022-01-14T21:19:00","slug":"questionnaire-medical-confidentiel","status":"publish","type":"page","link":"https:\/\/parodontierockland.com\/qm-en\/","title":{"rendered":"Medical questionnaire"},"content":{"rendered":"<p style=\"text-align: left;\"><span style=\"font-size: 24px; color: #ab004f;\">MEDICAL QUESTIONNAIRE<br \/>\n<\/span><\/p>\n<p>Use our SECURE online form to complete your health questionnaire. It\u2019s simple, easy and quick! Our online medical questionnaire will allow the periodontist and its team to provide you treatments in a safe manner. It is simple, secure and fast! It is important to complete it thoroughly and to inform us of any changes in your health status.<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_15' style='display:none'>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_15'  action='\/qm-en\/wp-json\/wp\/v2\/pages\/57' data-formid='15' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_15_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\"  ><div style=\"background-color:#ffffff;color:#545454;padding-top:5px;\npadding-bottom:5px;font-weight:bold;font-size:20px;\">YOUR INFORMATIONS<\/div><\/div><div id=\"field_15_11\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_11'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_15_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_8\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_8'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_15_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_35\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Birth Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_15_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_15_35_2_container'><label for='input_15_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label><select name='input_35[]' id='input_15_35_2'   aria-required='true'  ><option value=''>Jour<\/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_15_35_1_container'><label for='input_15_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label><select name='input_35[]' id='input_15_35_1'   aria-required='true'  ><option value=''>Mois<\/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_15_35_3_container'><label for='input_15_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label><select name='input_35[]' id='input_15_35_3'   aria-required='true'  ><option value=''>Ann\u00e9e<\/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><div id=\"field_15_129\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_129'>Residential address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_15_129' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_130\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_130'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_15_130' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_131\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_131'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_15_131' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_132\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_132'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_15_132' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_133\" class=\"gfield gfield--type-email gfield--width-two-thirds gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_133'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_133' id='input_15_133' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_15_36\" class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_36'>Home phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_15_36' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_37\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_37'>Office Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_15_37' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_38\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_38'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_15_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_200\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have dental insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_200'><div class='gchoice gchoice_15_200_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.1' type='checkbox'  value='Yes'  id='choice_15_200_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_200_1' id='label_15_200_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_200_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.2' type='checkbox'  value='No'  id='choice_15_200_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_200_2' id='label_15_200_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_46\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_46'>Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_15_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_201\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_201'>In case of emergency, contact (name)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_15_201' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_202\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_202'>Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_15_202' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_203\" class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_203'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_203' id='input_15_203' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_204\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_204'>Who referred you?<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_15_204' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_205\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_205'>Dentist<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_15_205' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_206\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr style=\"background-color:#52575b;height:3px;\"><\/hr><\/div><div id=\"field_15_155\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;padding-top:5px;\npadding-bottom:5px;font-weight:bold;font-size:20px;\">MEDICAL HISTORY<\/div><\/div><fieldset id=\"field_15_207\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Date of last medical examination<\/legend><div id='input_15_207' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_15_207_2_container'><label for='input_15_207_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label><select name='input_207[]' id='input_15_207_2'   aria-required='false'  ><option value=''>Jour<\/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_15_207_1_container'><label for='input_15_207_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label><select name='input_207[]' id='input_15_207_1'   aria-required='false'  ><option value=''>Mois<\/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_15_207_3_container'><label for='input_15_207_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label><select name='input_207[]' id='input_15_207_3'   aria-required='false'  ><option value=''>Ann\u00e9e<\/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><div id=\"field_15_157\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_157'>Family doctor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_15_157' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_161\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >1. Are you presently taking any medication or natural products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_161'><div class='gchoice gchoice_15_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Yes'  id='choice_15_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_161_1' id='label_15_161_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='No'  id='choice_15_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_161_2' id='label_15_161_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_162\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_162'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_15_162' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. Have there been any other medications in the past year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_167'><div class='gchoice gchoice_15_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Yes'  id='choice_15_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_167_1' id='label_15_167_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='No'  id='choice_15_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_167_2' id='label_15_167_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_168\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_168'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_15_168' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_165\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. Are you allergic to certain medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_165'><div class='gchoice gchoice_15_165_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.1' type='checkbox'  value='Yes'  id='choice_15_165_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_165_1' id='label_15_165_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_165_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.2' type='checkbox'  value='No'  id='choice_15_165_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_165_2' id='label_15_165_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_166\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_166'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_15_166' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_292\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >4. Do you have any other allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_292'><div class='gchoice gchoice_15_292_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_292.1' type='checkbox'  value='Yes'  id='choice_15_292_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_292_1' id='label_15_292_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_292_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_292.2' type='checkbox'  value='No'  id='choice_15_292_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_292_2' id='label_15_292_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_293\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_293'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_15_293' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_171\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-family:Open Sans;font-size:18px;font-weight:bold;color:#ab004f;\">5. Have you ever had any unusual reactions to (please check):?<\/style><\/div><fieldset id=\"field_15_295\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Local anesthesia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_295'><div class='gchoice gchoice_15_295_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_295.1' type='checkbox'  value='Yes'  id='choice_15_295_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_295_1' id='label_15_295_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_295_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_295.2' type='checkbox'  value='No'  id='choice_15_295_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_295_2' id='label_15_295_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_170\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_170'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_15_170' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_296\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Penicillin<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_296'><div class='gchoice gchoice_15_296_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_296.1' type='checkbox'  value='Yes'  id='choice_15_296_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_296_1' id='label_15_296_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_296_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_296.2' type='checkbox'  value='No'  id='choice_15_296_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_296_2' id='label_15_296_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_297\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_297'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_297' id='input_15_297' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_298\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Iodine<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_298'><div class='gchoice gchoice_15_298_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.1' type='checkbox'  value='Yes'  id='choice_15_298_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_298_1' id='label_15_298_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_298_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.2' type='checkbox'  value='No'  id='choice_15_298_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_298_2' id='label_15_298_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_299\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_299'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_299' id='input_15_299' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_300\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sulfonamide (sulfa)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_300'><div class='gchoice gchoice_15_300_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.1' type='checkbox'  value='Yes'  id='choice_15_300_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_300_1' id='label_15_300_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_300_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_300.2' type='checkbox'  value='No'  id='choice_15_300_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_300_2' id='label_15_300_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_301\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_301'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_301' id='input_15_301' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_302\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Other medications<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_302'><div class='gchoice gchoice_15_302_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_302.1' type='checkbox'  value='Yes'  id='choice_15_302_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_302_1' id='label_15_302_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_302_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_302.2' type='checkbox'  value='No'  id='choice_15_302_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_302_2' id='label_15_302_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_303\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_303'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_15_303' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_294\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-family:Open Sans;font-size:18px;font-weight:bold;color:#ab004f;\">6. Please check YES or NO to each of the current or past conditions:<\/style><\/div><div id=\"field_15_145\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Are you followed by a doctor?<\/div><fieldset id=\"field_15_140\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline single-column-form gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you followed by a doctor?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_140'><div class='gchoice gchoice_15_140_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.1' type='checkbox'  value='Yes'  id='choice_15_140_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_140_1' id='label_15_140_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_140_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.2' type='checkbox'  value='No'  id='choice_15_140_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_140_2' id='label_15_140_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_147\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Skin disease<\/div><fieldset id=\"field_15_148\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Skin disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_148'><div class='gchoice gchoice_15_148_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.1' type='checkbox'  value='Yes'  id='choice_15_148_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_148_1' id='label_15_148_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_148_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.2' type='checkbox'  value='No'  id='choice_15_148_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_148_2' id='label_15_148_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_152\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Were you ever hospitalized?<\/div><fieldset id=\"field_15_153\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Were you ever hospitalized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_153'><div class='gchoice gchoice_15_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Yes'  id='choice_15_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_153_1' id='label_15_153_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_153_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.2' type='checkbox'  value='No'  id='choice_15_153_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_153_2' id='label_15_153_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_150\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Eye problems<\/div><fieldset id=\"field_15_151\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline single-column-form gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eye problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_151'><div class='gchoice gchoice_15_151_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.1' type='checkbox'  value='Yes'  id='choice_15_151_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_151_1' id='label_15_151_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_151_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.2' type='checkbox'  value='No'  id='choice_15_151_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_151_2' id='label_15_151_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_174\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Blood problems (hemophilia, anemia, prolonged bleeding)<\/div><fieldset id=\"field_15_175\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline single-column-form gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Blood problems (hemophilia, anemia, prolonged bleeding)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_175'><div class='gchoice gchoice_15_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='Yes'  id='choice_15_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_175_1' id='label_15_175_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_175_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.2' type='checkbox'  value='No'  id='choice_15_175_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_175_2' id='label_15_175_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_172\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Earaches<\/div><fieldset id=\"field_15_173\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Earaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_173'><div class='gchoice gchoice_15_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Yes'  id='choice_15_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_173_1' id='label_15_173_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='No'  id='choice_15_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_173_2' id='label_15_173_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_178\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Heart disease (heart attack, angina, valvular disease, murmur)<\/div><fieldset id=\"field_15_179\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Heart disease (heart attack, angina, valvular disease, murmur)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_179'><div class='gchoice gchoice_15_179_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.1' type='checkbox'  value='Yes'  id='choice_15_179_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_179_1' id='label_15_179_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_179_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.2' type='checkbox'  value='No'  id='choice_15_179_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_179_2' id='label_15_179_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_176\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Heart infection (endocarditis)<\/div><fieldset id=\"field_15_177\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Heart infection (endocarditis)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_177'><div class='gchoice gchoice_15_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='Yes'  id='choice_15_177_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_177_1' id='label_15_177_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_177_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.2' type='checkbox'  value='No'  id='choice_15_177_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_177_2' id='label_15_177_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_182\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Replacement of heart valves \/ stent<\/div><fieldset id=\"field_15_183\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Replacement of heart valves \/ stent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_183'><div class='gchoice gchoice_15_183_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.1' type='checkbox'  value='Yes'  id='choice_15_183_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_183_1' id='label_15_183_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_183_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.2' type='checkbox'  value='No'  id='choice_15_183_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_183_2' id='label_15_183_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_180\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Osteoporosis - Prevention\/treatment (tablet)<\/div><fieldset id=\"field_15_181\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoporosis - Prevention\/treatment (tablet)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_181'><div class='gchoice gchoice_15_181_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Yes'  id='choice_15_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_181_1' id='label_15_181_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_181_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.2' type='checkbox'  value='No'  id='choice_15_181_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_181_2' id='label_15_181_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_186\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Osteoporosis - Annual or monthly injection<\/div><fieldset id=\"field_15_187\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoporosis - Annual or monthly injection<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_187'><div class='gchoice gchoice_15_187_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.1' type='checkbox'  value='Yes'  id='choice_15_187_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_187_1' id='label_15_187_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_187_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.2' type='checkbox'  value='No'  id='choice_15_187_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_187_2' id='label_15_187_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_184\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Chronic Pain<\/div><fieldset id=\"field_15_185\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic Pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_185'><div class='gchoice gchoice_15_185_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.1' type='checkbox'  value='Yes'  id='choice_15_185_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_185_1' id='label_15_185_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_185_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.2' type='checkbox'  value='No'  id='choice_15_185_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_185_2' id='label_15_185_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_190\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Blood pressure<\/div><fieldset id=\"field_15_191\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_191'><div class='gchoice gchoice_15_191_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.1' type='checkbox'  value='High'  id='choice_15_191_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_191_1' id='label_15_191_1' class='gform-field-label gform-field-label--type-inline'>High<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_191_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.2' type='checkbox'  value='Low'  id='choice_15_191_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_191_2' id='label_15_191_2' class='gform-field-label gform-field-label--type-inline'>Low<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_191_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.3' type='checkbox'  value='No'  id='choice_15_191_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_191_3' id='label_15_191_3' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_188\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Cholesterol<\/div><fieldset id=\"field_15_189\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cholesterol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_189'><div class='gchoice gchoice_15_189_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.1' type='checkbox'  value='Yes'  id='choice_15_189_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_189_1' id='label_15_189_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_189_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.2' type='checkbox'  value='No'  id='choice_15_189_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_189_2' id='label_15_189_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_192\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Stroke (CVA)<\/div><fieldset id=\"field_15_195\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Stroke (CVA)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_195'><div class='gchoice gchoice_15_195_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.1' type='checkbox'  value='Yes'  id='choice_15_195_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_195_1' id='label_15_195_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_195_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.2' type='checkbox'  value='No'  id='choice_15_195_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_195_2' id='label_15_195_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_194\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Epilepsy<\/div><fieldset id=\"field_15_193\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_193'><div class='gchoice gchoice_15_193_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.1' type='checkbox'  value='Yes'  id='choice_15_193_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_193_1' id='label_15_193_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_193_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.2' type='checkbox'  value='No'  id='choice_15_193_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_193_2' id='label_15_193_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_196\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Nervous system disorders\/diseases<\/div><fieldset id=\"field_15_197\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nervous system disorders\/diseases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_197'><div class='gchoice gchoice_15_197_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.1' type='checkbox'  value='Yes'  id='choice_15_197_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_197_1' id='label_15_197_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_197_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.2' type='checkbox'  value='No'  id='choice_15_197_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_197_2' id='label_15_197_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_198\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Psychiatric Disorders\/Diseases<\/div><fieldset id=\"field_15_199\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Troubles \/ maladies psychiatriques<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_199'><div class='gchoice gchoice_15_199_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.1' type='checkbox'  value='Yes'  id='choice_15_199_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_199_1' id='label_15_199_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_199_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.2' type='checkbox'  value='No'  id='choice_15_199_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_199_2' id='label_15_199_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_208\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Dizziness, fainting<\/div><fieldset id=\"field_15_209\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dizziness, fainting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_209'><div class='gchoice gchoice_15_209_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.1' type='checkbox'  value='Yes'  id='choice_15_209_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_209_1' id='label_15_209_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_209_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.2' type='checkbox'  value='No'  id='choice_15_209_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_209_2' id='label_15_209_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_210\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Frequent colds or sinusitis<\/div><fieldset id=\"field_15_211\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequent colds or sinusitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_211'><div class='gchoice gchoice_15_211_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.1' type='checkbox'  value='Yes'  id='choice_15_211_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_211_1' id='label_15_211_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_211_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.2' type='checkbox'  value='No'  id='choice_15_211_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_211_2' id='label_15_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_214\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Frequent headaches<\/div><fieldset id=\"field_15_213\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Frequent headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_213'><div class='gchoice gchoice_15_213_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.1' type='checkbox'  value='Yes'  id='choice_15_213_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_213_1' id='label_15_213_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_213_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.2' type='checkbox'  value='No'  id='choice_15_213_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_213_2' id='label_15_213_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_212\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Tuberculosis \/ lung problems<\/div><fieldset id=\"field_15_215\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tuberculosis \/ lung problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_215'><div class='gchoice gchoice_15_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Yes'  id='choice_15_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_215_1' id='label_15_215_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='No'  id='choice_15_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_215_2' id='label_15_215_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_216\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Liver problem (hepatitis A, B, C, cirrhosis, etc.)<\/div><fieldset id=\"field_15_217\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Liver problem (hepatitis A, B, C, cirrhosis, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_217'><div class='gchoice gchoice_15_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Yes'  id='choice_15_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_217_1' id='label_15_217_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='No'  id='choice_15_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_217_2' id='label_15_217_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_218\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Asthma\n\n<\/div><fieldset id=\"field_15_219\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_219'><div class='gchoice gchoice_15_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Yes'  id='choice_15_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_219_1' id='label_15_219_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='No'  id='choice_15_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_219_2' id='label_15_219_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_222\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Disorders or diseases of the digestive system<\/div><fieldset id=\"field_15_223\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Disorders or diseases of the digestive system<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_223'><div class='gchoice gchoice_15_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Yes'  id='choice_15_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_223_1' id='label_15_223_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='No'  id='choice_15_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_223_2' id='label_15_223_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_220\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Hay fever \/ seasonal allergies<\/div><fieldset id=\"field_15_221\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Hay fever \/ seasonal allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_221'><div class='gchoice gchoice_15_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Yes'  id='choice_15_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_221_1' id='label_15_221_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='No'  id='choice_15_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_221_2' id='label_15_221_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_226\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Stomach problems (Ulcer or reflux)<\/div><fieldset id=\"field_15_227\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Stomach problems (Ulcer or reflux)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_227'><div class='gchoice gchoice_15_227_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.1' type='checkbox'  value='Yes'  id='choice_15_227_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_227_1' id='label_15_227_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_227_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.2' type='checkbox'  value='No'  id='choice_15_227_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_227_2' id='label_15_227_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_224\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Cancer (tumor)<\/div><fieldset id=\"field_15_225\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer (tumor)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_225'><div class='gchoice gchoice_15_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Yes'  id='choice_15_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_225_1' id='label_15_225_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='No'  id='choice_15_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_225_2' id='label_15_225_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_228\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Radiotherapy<\/div><fieldset id=\"field_15_231\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Radiotherapy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_231'><div class='gchoice gchoice_15_231_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.1' type='checkbox'  value='Yes'  id='choice_15_231_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_231_1' id='label_15_231_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_231_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.2' type='checkbox'  value='No'  id='choice_15_231_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_231_2' id='label_15_231_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_230\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Chemotherapy<\/div><fieldset id=\"field_15_229\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chemotherapy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_229'><div class='gchoice gchoice_15_229_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.1' type='checkbox'  value='Yes'  id='choice_15_229_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_229_1' id='label_15_229_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_229_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.2' type='checkbox'  value='No'  id='choice_15_229_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_229_2' id='label_15_229_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_234\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Kidney disorders or diseases<\/div><fieldset id=\"field_15_235\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Kidney disorders or diseases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_235'><div class='gchoice gchoice_15_235_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.1' type='checkbox'  value='Yes'  id='choice_15_235_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_235_1' id='label_15_235_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_235_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.2' type='checkbox'  value='No'  id='choice_15_235_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_235_2' id='label_15_235_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_232\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Diabetes (Type 1 or 2)\n\n<\/div><fieldset id=\"field_15_233\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Diabetes (Type 1 or 2)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_233'><div class='gchoice gchoice_15_233_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_233.1' type='checkbox'  value='Yes'  id='choice_15_233_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_233_1' id='label_15_233_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_233_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_233.2' type='checkbox'  value='No'  id='choice_15_233_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_233_2' id='label_15_233_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_238\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Thyroid disorders (Hyper or hypo)<\/div><fieldset id=\"field_15_239\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Thyroid disorders (Hyper or hypo)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_239'><div class='gchoice gchoice_15_239_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.1' type='checkbox'  value='Yes'  id='choice_15_239_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_239_1' id='label_15_239_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_239_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.2' type='checkbox'  value='No'  id='choice_15_239_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_239_2' id='label_15_239_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_236\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Anxiety<\/div><fieldset id=\"field_15_237\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anxiety<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_237'><div class='gchoice gchoice_15_237_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.1' type='checkbox'  value='Yes'  id='choice_15_237_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_237_1' id='label_15_237_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_237_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.2' type='checkbox'  value='No'  id='choice_15_237_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_237_2' id='label_15_237_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_242\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Joint replacement (knee\/hip)<\/div><fieldset id=\"field_15_243\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Joint replacement (knee\/hip)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_243'><div class='gchoice gchoice_15_243_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_243.1' type='checkbox'  value='Yes'  id='choice_15_243_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_243_1' id='label_15_243_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_243_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_243.2' type='checkbox'  value='No'  id='choice_15_243_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_243_2' id='label_15_243_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_240\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Organ transplant \/ medical implant<\/div><fieldset id=\"field_15_241\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Organ transplant \/ medical implant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_241'><div class='gchoice gchoice_15_241_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.1' type='checkbox'  value='Yes'  id='choice_15_241_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_241_1' id='label_15_241_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_241_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.2' type='checkbox'  value='No'  id='choice_15_241_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_241_2' id='label_15_241_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_246\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Sexually transmitted and blood-borne infections (STBBIs)<\/div><fieldset id=\"field_15_247\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sexually transmitted and blood-borne infections (STBBIs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_247'><div class='gchoice gchoice_15_247_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_247.1' type='checkbox'  value='Yes'  id='choice_15_247_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_247_1' id='label_15_247_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_247_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_247.2' type='checkbox'  value='No'  id='choice_15_247_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_247_2' id='label_15_247_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_244\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Are you HIV positive?<\/div><fieldset id=\"field_15_245\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you HIV positive?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_245'><div class='gchoice gchoice_15_245_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_245.1' type='checkbox'  value='Yes'  id='choice_15_245_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_245_1' id='label_15_245_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_245_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_245.2' type='checkbox'  value='No'  id='choice_15_245_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_245_2' id='label_15_245_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_259\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Substance abuse<\/div><fieldset id=\"field_15_251\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Substance abuse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_251'><div class='gchoice gchoice_15_251_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.1' type='checkbox'  value='Yes'  id='choice_15_251_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_251_1' id='label_15_251_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_251_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.2' type='checkbox'  value='No'  id='choice_15_251_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_251_2' id='label_15_251_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_248\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do you use drugs<\/div><fieldset id=\"field_15_249\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you use drugs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_249'><div class='gchoice gchoice_15_249_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_249.1' type='checkbox'  value='Yes'  id='choice_15_249_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_249_1' id='label_15_249_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_249_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_249.2' type='checkbox'  value='No'  id='choice_15_249_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_249_2' id='label_15_249_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_252\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is there an illness, physical condition or problem that is not listed above that we should know about?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_252'><div class='gchoice gchoice_15_252_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_252.1' type='checkbox'  value='Yes'  id='choice_15_252_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_252_1' id='label_15_252_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_252_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_252.2' type='checkbox'  value='No'  id='choice_15_252_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_252_2' id='label_15_252_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_83\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_83'>If yes, specify<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_15_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_255\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_255'><div class='gchoice gchoice_15_255_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.1' type='checkbox'  value='Yes - Cigarette'  id='choice_15_255_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_255_1' id='label_15_255_1' class='gform-field-label gform-field-label--type-inline'>Yes - Cigarette<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_255_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.2' type='checkbox'  value='Yes - Cannabis'  id='choice_15_255_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_255_2' id='label_15_255_2' class='gform-field-label gform-field-label--type-inline'>Yes - Cannabis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_255_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.3' type='checkbox'  value='Yes - Vaping'  id='choice_15_255_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_255_3' id='label_15_255_3' class='gform-field-label gform-field-label--type-inline'>Yes - Vaping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_255_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.4' type='checkbox'  value='No'  id='choice_15_255_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_255_4' id='label_15_255_4' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_256\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_256'>If yes, cig.\/day and nb. year<\/label><div class='ginput_container ginput_container_text'><input name='input_256' id='input_15_256' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_257\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you drinking alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_257'><div class='gchoice gchoice_15_257_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.1' type='checkbox'  value='Yes'  id='choice_15_257_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_257_1' id='label_15_257_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_257_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.2' type='checkbox'  value='No'  id='choice_15_257_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_257_2' id='label_15_257_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_258\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_258'>Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_258' id='input_15_258' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_250\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"color:#b5004f;font-size:18px;\"><strong>Woman only<\/strong><\/span><\/div><fieldset id=\"field_15_260\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_260'><div class='gchoice gchoice_15_260_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.1' type='checkbox'  value='Yes'  id='choice_15_260_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_260_1' id='label_15_260_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_260_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.2' type='checkbox'  value='No'  id='choice_15_260_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_260_2' id='label_15_260_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_262\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you breastfeeding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_262'><div class='gchoice gchoice_15_262_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.1' type='checkbox'  value='Yes'  id='choice_15_262_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_262_1' id='label_15_262_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_262_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.2' type='checkbox'  value='No'  id='choice_15_262_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_262_2' id='label_15_262_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_15_263\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Birth control pill?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_263'><div class='gchoice gchoice_15_263_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.1' type='checkbox'  value='Yes'  id='choice_15_263_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_263_1' id='label_15_263_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_263_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.2' type='checkbox'  value='No'  id='choice_15_263_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_263_2' id='label_15_263_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_89\" 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\"  ><hr style=\"background-color:#52575b;height:3px;\"><\/hr><\/div><div id=\"field_15_267\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;padding-top:5px;\npadding-bottom:5px;font-weight:bold;font-size:20px;\">DENTAL HISTORY<\/div><\/div><div id=\"field_15_272\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-family:Open Sans;font-size:18px;font-weight:bold;color:#ab004f;\">1. Please check YES or NO to each of the questions:<\/style><\/div><div id=\"field_15_269\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do your gums bleed?<\/div><fieldset id=\"field_15_268\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do your gums bleed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_268'><div class='gchoice gchoice_15_268_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_268.1' type='checkbox'  value='Yes'  id='choice_15_268_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_268_1' id='label_15_268_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_268_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_268.2' type='checkbox'  value='No'  id='choice_15_268_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_268_2' id='label_15_268_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_270\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do you feel you have bad breath?<\/div><fieldset id=\"field_15_271\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you feel you have bad breath?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_271'><div class='gchoice gchoice_15_271_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_271.1' type='checkbox'  value='Yes'  id='choice_15_271_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_271_1' id='label_15_271_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_271_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_271.2' type='checkbox'  value='No'  id='choice_15_271_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_271_2' id='label_15_271_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_275\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do you grind or clench your teeth day or night?<\/div><fieldset id=\"field_15_276\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you grind or clench your teeth day or night?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_276'><div class='gchoice gchoice_15_276_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_276.1' type='checkbox'  value='Yes'  id='choice_15_276_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_276_1' id='label_15_276_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_276_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_276.2' type='checkbox'  value='No'  id='choice_15_276_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_276_2' id='label_15_276_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_273\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Are your teeth sensitive?<\/div><fieldset id=\"field_15_274\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are your teeth sensitive?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_274'><div class='gchoice gchoice_15_274_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_274.1' type='checkbox'  value='Yes'  id='choice_15_274_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_274_1' id='label_15_274_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_274_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_274.2' type='checkbox'  value='No'  id='choice_15_274_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_274_2' id='label_15_274_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_279\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do you have receding gums?<\/div><fieldset id=\"field_15_280\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have receding gums?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_280'><div class='gchoice gchoice_15_280_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_280.1' type='checkbox'  value='Yes'  id='choice_15_280_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_280_1' id='label_15_280_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_280_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_280.2' type='checkbox'  value='No'  id='choice_15_280_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_280_2' id='label_15_280_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_277\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Have you noticed a movement in your teeth?<\/div><fieldset id=\"field_15_278\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you noticed a movement in your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_278'><div class='gchoice gchoice_15_278_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_278.1' type='checkbox'  value='Yes'  id='choice_15_278_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_278_1' id='label_15_278_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_278_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_278.2' type='checkbox'  value='No'  id='choice_15_278_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_278_2' id='label_15_278_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_283\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Do you feel that your teeth are mobile?<\/div><fieldset id=\"field_15_284\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you feel that your teeth are mobile?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_284'><div class='gchoice gchoice_15_284_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_284.1' type='checkbox'  value='Yes'  id='choice_15_284_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_284_1' id='label_15_284_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_284_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_284.2' type='checkbox'  value='No'  id='choice_15_284_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_284_2' id='label_15_284_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_281\" class=\"gfield gfield--type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Does food ever get heapped between your teeth?<\/div><fieldset id=\"field_15_282\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Does food ever get heapped between your teeth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_282'><div class='gchoice gchoice_15_282_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_282.1' type='checkbox'  value='Yes'  id='choice_15_282_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_282_1' id='label_15_282_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_282_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_282.2' type='checkbox'  value='No'  id='choice_15_282_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_282_2' id='label_15_282_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_285\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-family:Open Sans;font-size:18px;font-weight:bold;color:#ab004f;\">2. How often do you visit your dentist?<\/style><\/div><fieldset id=\"field_15_286\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. How often do you visit your dentist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_286'><div class='gchoice gchoice_15_286_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.1' type='checkbox'  value='3-4 month'  id='choice_15_286_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_1' id='label_15_286_1' class='gform-field-label gform-field-label--type-inline'>3-4 month<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_286_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.2' type='checkbox'  value='6 month'  id='choice_15_286_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_2' id='label_15_286_2' class='gform-field-label gform-field-label--type-inline'>6 month<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_286_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.3' type='checkbox'  value='9 month'  id='choice_15_286_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_3' id='label_15_286_3' class='gform-field-label gform-field-label--type-inline'>9 month<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_286_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.4' type='checkbox'  value='12 month'  id='choice_15_286_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_4' id='label_15_286_4' class='gform-field-label gform-field-label--type-inline'>12 month<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_286_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.5' type='checkbox'  value='irregularly'  id='choice_15_286_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_5' id='label_15_286_5' class='gform-field-label gform-field-label--type-inline'>irregularly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_286_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.6' type='checkbox'  value='other'  id='choice_15_286_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_286_6' id='label_15_286_6' 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_15_287\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_287'>Last visit:<\/label><div class='ginput_container ginput_container_text'><input name='input_287' id='input_15_287' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_288\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_288'>Reason for visit:<\/label><div class='ginput_container ginput_container_text'><input name='input_288' id='input_15_288' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_289\" class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_289'>Last dental cleaning:<\/label><div class='ginput_container ginput_container_text'><input name='input_289' id='input_15_289' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_290\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"font-family:Open Sans;font-size:18px;font-weight:bold;color:#ab004f;\">3. Have you ever had? (please check):<\/style><\/div><fieldset id=\"field_15_291\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. A quelle fr\u00e9quence visitez-vous votre dentiste?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_291'><div class='gchoice gchoice_15_291_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.1' type='checkbox'  value='Oral surgery'  id='choice_15_291_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_291_1' id='label_15_291_1' class='gform-field-label gform-field-label--type-inline'>Oral surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_291_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.2' type='checkbox'  value='Periodontal treatment'  id='choice_15_291_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_291_2' id='label_15_291_2' class='gform-field-label gform-field-label--type-inline'>Periodontal treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_291_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.3' type='checkbox'  value='Orthodontic treatment'  id='choice_15_291_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_291_3' id='label_15_291_3' class='gform-field-label gform-field-label--type-inline'>Orthodontic treatment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_291_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.4' type='checkbox'  value='Night guard'  id='choice_15_291_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_291_4' id='label_15_291_4' class='gform-field-label gform-field-label--type-inline'>Night guard<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_291_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.5' type='checkbox'  value='Other device'  id='choice_15_291_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_291_5' id='label_15_291_5' class='gform-field-label gform-field-label--type-inline'>Other device<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_91\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#ab004f;color:#ffffff;border:solid 1px #ab004f;padding:10px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div><\/div><fieldset id=\"field_15_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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Certification of medical history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_15_88_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_88_1' >I, the undersigned, hereby declare that I have read, understood and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Parodontie Rockland. I have been informed that my file will be kept in the office at all the time and that only the periodontist and its auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.<\/label><input type='hidden' name='input_88.2' value='I, the undersigned, hereby declare that I have read, understood and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Parodontie Rockland. I have been informed that my file will be kept in the office at all the time and that only the periodontist and its auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_15_90\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Certification of dental history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_90.1' id='input_15_90_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_90_1' >I, the undersigned, declare that I answered the questions to the best of my knowledge. I was also able and took the time to ask the periodontist all the questions I had regarding the present intervention. I understand, that the object of this questionnaire is to obtain the best results possible.<\/label><input type='hidden' name='input_90.2' value='I, the undersigned, declare that I answered the questions to the best of my knowledge. I was also able and took the time to ask the periodontist all the questions I had regarding the present intervention. I understand, that the object of this questionnaire is to obtain the best results possible.' class='gform_hidden' \/><input type='hidden' name='input_90.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_15_304\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of Collection, use, and disclosure of personal information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_304.1' id='input_15_304_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_15_304\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_304_1' >I hereby give my consent to the collection, use and disclosure of my personal information by PARODONTIE ROCKLAND for the purpose of providing dental services.<\/label><input type='hidden' name='input_304.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by PARODONTIE ROCKLAND for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_304.3' value='7' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_15_304' tabindex='0'>More information about our <a href=\"https:\/\/parodontierockland.com\/en\/privacy-policy\/\" target=\"_blank\" rel=\"noopener\">Cookie Policy<\/a><\/div><\/fieldset><div id=\"field_15_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_2'>Patient or Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_15_2_valid' id='input_15_2_valid' \/><canvas id='input_15_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #ab004f; background-color:#ebebeb; cursor: url(https:\/\/parodontierockland.com\/qm-en\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_15_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_15_2_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_15_2_data' name='input_15_2_data' value=''><\/div><\/div><div id=\"field_15_33\" class=\"gfield gfield--type-text gf_readonly gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_15_33' type='text' value='18 April 2026 01h48' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_124\" class=\"gfield gfield--type-checkbox gfield--type-choice blanc field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >-<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_124'><div class='gchoice gchoice_15_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='R\u00e9serv\u00e9 \u00e0 l&#039;administration'  id='choice_15_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_124_1' id='label_15_124_1' class='gform-field-label gform-field-label--type-inline'>R\u00e9serv\u00e9 \u00e0 l'administration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_15_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='R\u00e9serv\u00e9 \u00e0 l&#039;administration'  id='choice_15_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_15_124_2' id='label_15_124_2' class='gform-field-label gform-field-label--type-inline'>R\u00e9serv\u00e9 \u00e0 l'administration<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_15_110\" 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\"  ><br><br><div style=\"background-color:#66686c;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">** RESERVED TO THE ADMINISTRATION**<\/div><\/div><div id=\"field_15_112\" class=\"gfield gfield--type-textarea grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_112'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_15_112' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_15_113\" class=\"gfield gfield--type-textarea grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_113'>Precautions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_15_113' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_15_111\" class=\"gfield gfield--type-consent gfield--type-choice grisadmin gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of the specialist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_111.1' id='input_15_111_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_15_111_1' >I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.<\/label><input type='hidden' name='input_111.2' value='I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.' class='gform_hidden' \/><input type='hidden' name='input_111.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_15_117\" class=\"gfield gfield--type-signature grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_117'>Specialist Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_15_117_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_15_117_valid' id='input_15_117_valid' \/><canvas id='input_15_117' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #545454; background-color:#ebebeb; cursor: url(https:\/\/parodontierockland.com\/qm-en\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_15_117_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_15_117_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_15_117_data' name='input_15_117_data' value=''><\/div><\/div><div id=\"field_15_116\" class=\"gfield gfield--type-text grisadmin gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_116'>Specialist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_15_116' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_15_114\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_15_114'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_114' id='input_15_114' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_15_114_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_15_114_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_15_114' class='gform_hidden' value='https:\/\/parodontierockland.com\/qm-en\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_15_118\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_15_118'>is Approval<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_15_118' type='text' value='1' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_15_119\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Who is this for?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_15_119'>\n\t\t\t<div class='gchoice 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