{"id":57,"date":"2020-06-02T09:38:21","date_gmt":"2020-06-02T13:38:21","guid":{"rendered":"https:\/\/parodontierockland.com\/qm-fr\/?page_id=57"},"modified":"2022-01-14T14:12:16","modified_gmt":"2022-01-14T19:12:16","slug":"questionnaire-medical-confidentiel","status":"publish","type":"page","link":"https:\/\/parodontierockland.com\/qm-fr\/","title":{"rendered":"Questionnaire m\u00e9dical confidentiel"},"content":{"rendered":"<p style=\"text-align: left;\"><strong><span style=\"font-size: 24px; color: #ab004f;\">QUESTIONNAIRE M\u00c9DICAL<\/span><\/strong><\/p>\n<p>Utilisez notre formulaire en ligne S\u00c9CURIS\u00c9 pour remplir votre questionnaire de sant\u00e9. C\u2019est simple, facile et rapide! Ce questionnaire permettra au parodontiste et \u00e0 son \u00e9quipe de prodiguer les meilleurs soins possibles et de r\u00e9duire le risque de complication(s) m\u00e9dicale(s). Il est de l\u2019int\u00e9r\u00eat du patient d\u2019y r\u00e9pondre avec attention et d\u2019aviser de tout changement \u00e0 son \u00e9tat de sant\u00e9.<\/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_11' 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_11'  action='\/qm-fr\/wp-json\/wp\/v2\/pages\/57' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_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;\">RENSEIGNEMENTS PERSONNELS<\/div><\/div><div id=\"field_11_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_11_11'>Nom<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_11_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_8'>Pr\u00e9nom<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_11_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_11_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_11_35_2_container'><label for='input_11_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_11_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_11_35_1_container'><label for='input_11_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_11_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_11_35_3_container'><label for='input_11_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_11_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_11_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_11_129'>Adresse r\u00e9sidentielle<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_11_129' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_130'>Ville<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_11_130' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_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_11_131' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_132'>Code postal<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_11_132' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_133'>Courriel<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_11_133' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_11_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_11_36'>T\u00e9l\u00e9phone domicile<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_11_36' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_37'>T\u00e9l\u00e9phone bureau<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_11_37' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_38'>Cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_11_38' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >Avez-vous une assurance dentaire?<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_11_200'><div class='gchoice gchoice_11_200_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.1' type='checkbox'  value='Oui'  id='choice_11_200_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_200_1' id='label_11_200_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_200_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.2' type='checkbox'  value='Non'  id='choice_11_200_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_200_2' id='label_11_200_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_46'>Employeur<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_11_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_201'>En cas d&#039;urgence, contacter (nom)<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_11_201' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_202'>Lien<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_11_202' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_203'>T\u00e9l\u00e9phone<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_11_203' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_204'>Qui vous a r\u00e9f\u00e9r\u00e9?<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_11_204' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_205'>Dentiste<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_11_205' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_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;\">HISTOIRE M\u00c9DICALE<\/div><\/div><fieldset id=\"field_11_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 du dernier examen m\u00e9dical<\/legend><div id='input_11_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_11_207_2_container'><label for='input_11_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_11_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_11_207_1_container'><label for='input_11_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_11_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_11_207_3_container'><label for='input_11_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_11_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_11_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_11_157'>M\u00e9decin de famille<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_11_157' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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. Prenez-vous des m\u00e9dicaments ou des produits naturels?<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_11_161'><div class='gchoice gchoice_11_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Oui'  id='choice_11_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_161_1' id='label_11_161_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='Non'  id='choice_11_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_161_2' id='label_11_161_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_162'>Si oui, pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_11_162' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_163\" 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. Y a-t-il eu d\u2019autres m\u00e9dicaments durant la derni\u00e8re ann\u00e9e?<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_11_163'><div class='gchoice gchoice_11_163_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_163.1' type='checkbox'  value='Oui'  id='choice_11_163_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_163_1' id='label_11_163_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_163_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_163.2' type='checkbox'  value='Non'  id='choice_11_163_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_163_2' id='label_11_163_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_164\" 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_11_164'>Si oui, pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_11_164' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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. \u00cates-vous allergique \u00e0 certains m\u00e9dicaments?<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_11_165'><div class='gchoice gchoice_11_165_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.1' type='checkbox'  value='Oui'  id='choice_11_165_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_165_1' id='label_11_165_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_165_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.2' type='checkbox'  value='Non'  id='choice_11_165_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_165_2' id='label_11_165_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_166'>Si oui, pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_11_166' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >4. Avez-vous d&#039;autres 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_11_167'><div class='gchoice gchoice_11_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Oui'  id='choice_11_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_167_1' id='label_11_167_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='Non'  id='choice_11_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_167_2' id='label_11_167_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_168'>Si oui, pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_11_168' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_292\" 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. Avez-vous d\u00e9j\u00e0 eu des r\u00e9actions peu commune \u00e0 (s.v.p. cocher):?<\/span><\/div><fieldset id=\"field_11_293\" 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' >Anesth\u00e9sie locale<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_293'><div class='gchoice gchoice_11_293_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_293.1' type='checkbox'  value='Oui'  id='choice_11_293_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_293_1' id='label_11_293_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_293_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_293.2' type='checkbox'  value='Non'  id='choice_11_293_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_293_2' id='label_11_293_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_294\" 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_11_294'>Si oui, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_294' id='input_11_294' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >P\u00e9nicilline<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_295'><div class='gchoice gchoice_11_295_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_295.1' type='checkbox'  value='Oui'  id='choice_11_295_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_295_1' id='label_11_295_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_295_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_295.2' type='checkbox'  value='Non'  id='choice_11_295_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_295_2' id='label_11_295_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_296\" 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_11_296'>Si oui, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_11_296' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_297\" 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' >Iode<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_297'><div class='gchoice gchoice_11_297_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_297.1' type='checkbox'  value='Oui'  id='choice_11_297_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_297_1' id='label_11_297_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_297_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_297.2' type='checkbox'  value='Non'  id='choice_11_297_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_297_2' id='label_11_297_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_298\" 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_11_298'>Si oui, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_298' id='input_11_298' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_299\" 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' >Sulfamide (sulfa)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_299'><div class='gchoice gchoice_11_299_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_299.1' type='checkbox'  value='Oui'  id='choice_11_299_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_299_1' id='label_11_299_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_299_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_299.2' type='checkbox'  value='Non'  id='choice_11_299_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_299_2' id='label_11_299_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_300\" 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_11_300'>Si oui, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_300' id='input_11_300' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_301\" 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' >Autre m\u00e9dicament<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_301'><div class='gchoice gchoice_11_301_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_301.1' type='checkbox'  value='Oui'  id='choice_11_301_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_301_1' id='label_11_301_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_301_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_301.2' type='checkbox'  value='Non'  id='choice_11_301_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_301_2' id='label_11_301_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_302\" 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_11_302'>Si oui, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_302' id='input_11_302' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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;\">6. Veuillez cocher OUI ou NON \u00e0 chacune des conditions actuelles ou pass\u00e9es:<\/style><\/div><div id=\"field_11_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\"  >\u00cates-vous pr\u00e9sentement suivi par un m\u00e9decin?<\/div><fieldset id=\"field_11_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' >\u00cates-vous pr\u00e9sentement suivi par un m\u00e9decin?<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_11_140'><div class='gchoice gchoice_11_140_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.1' type='checkbox'  value='Oui'  id='choice_11_140_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_140_1' id='label_11_140_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_140_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.2' type='checkbox'  value='Non'  id='choice_11_140_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_140_2' id='label_11_140_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Maladies de peau<\/div><fieldset id=\"field_11_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' >Maladies de peau<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_11_148'><div class='gchoice gchoice_11_148_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.1' type='checkbox'  value='Oui'  id='choice_11_148_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_148_1' id='label_11_148_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_148_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.2' type='checkbox'  value='Non'  id='choice_11_148_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_148_2' id='label_11_148_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9?<\/div><fieldset id=\"field_11_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' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9?<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_11_153'><div class='gchoice gchoice_11_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Oui'  id='choice_11_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_153_1' id='label_11_153_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_153_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.2' type='checkbox'  value='Non'  id='choice_11_153_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_153_2' id='label_11_153_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Probl\u00e8mes oculaires (yeux)<\/div><fieldset id=\"field_11_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' >Probl\u00e8mes oculaires (yeux)<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_11_151'><div class='gchoice gchoice_11_151_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.1' type='checkbox'  value='Oui'  id='choice_11_151_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_151_1' id='label_11_151_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_151_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.2' type='checkbox'  value='Non'  id='choice_11_151_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_151_2' id='label_11_151_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Probl\u00e8mes sanguins (h\u00e9mophilie, an\u00e9mie, saignements prolong\u00e9s)<\/div><fieldset id=\"field_11_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' >Probl\u00e8mes sanguins (h\u00e9mophilie, an\u00e9mie, saignements prolong\u00e9s)<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_11_175'><div class='gchoice gchoice_11_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='Oui'  id='choice_11_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_175_1' id='label_11_175_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_175_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.2' type='checkbox'  value='Non'  id='choice_11_175_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_175_2' id='label_11_175_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Maux d'oreilles<\/div><fieldset id=\"field_11_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' >Maux d&#039;oreilles<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_11_173'><div class='gchoice gchoice_11_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Oui'  id='choice_11_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_173_1' id='label_11_173_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='Non'  id='choice_11_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_173_2' id='label_11_173_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Infarctus, angine, chirurgie cardiaque<\/div><fieldset id=\"field_11_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' >Infarctus, angine, chirurgie cardiaque<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_11_179'><div class='gchoice gchoice_11_179_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.1' type='checkbox'  value='Oui'  id='choice_11_179_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_179_1' id='label_11_179_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_179_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.2' type='checkbox'  value='Non'  id='choice_11_179_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_179_2' id='label_11_179_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Infection du coeur (endocardite)<\/div><fieldset id=\"field_11_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' >Infection du coeur (endocardite)<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_11_177'><div class='gchoice gchoice_11_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='Oui'  id='choice_11_177_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_177_1' id='label_11_177_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_177_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.2' type='checkbox'  value='Non'  id='choice_11_177_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_177_2' id='label_11_177_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >R\u00e9paration \/ remplacement de valve \/ tuteur (stent)<\/div><fieldset id=\"field_11_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' >R\u00e9paration \/ remplacement de valve \/ tuteur (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_11_183'><div class='gchoice gchoice_11_183_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.1' type='checkbox'  value='Oui'  id='choice_11_183_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_183_1' id='label_11_183_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_183_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.2' type='checkbox'  value='Non'  id='choice_11_183_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_183_2' id='label_11_183_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Ost\u00e9oporose - Pr\u00e9vention\/traitement (comprim\u00e9) <\/div><fieldset id=\"field_11_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' >Ost\u00e9oporose - Pr\u00e9vention\/traitement (comprim\u00e9)<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_11_181'><div class='gchoice gchoice_11_181_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Oui'  id='choice_11_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_181_1' id='label_11_181_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_181_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.2' type='checkbox'  value='Non'  id='choice_11_181_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_181_2' id='label_11_181_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Ost\u00e9oporose - Injection annuelle ou mensuelle <\/div><fieldset id=\"field_11_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' >Ost\u00e9oporose - Injection annuelle ou mensuelle<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_11_187'><div class='gchoice gchoice_11_187_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.1' type='checkbox'  value='Oui'  id='choice_11_187_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_187_1' id='label_11_187_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_187_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.2' type='checkbox'  value='Non'  id='choice_11_187_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_187_2' id='label_11_187_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Douleur chronique<\/div><fieldset id=\"field_11_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' >Douleur chronique<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_11_185'><div class='gchoice gchoice_11_185_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.1' type='checkbox'  value='Oui'  id='choice_11_185_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_185_1' id='label_11_185_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_185_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.2' type='checkbox'  value='Non'  id='choice_11_185_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_185_2' id='label_11_185_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Tension art\u00e9rielle<\/div><fieldset id=\"field_11_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' >Tension art\u00e9rielle<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_11_191'><div class='gchoice gchoice_11_191_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.1' type='checkbox'  value='Haute'  id='choice_11_191_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_191_1' id='label_11_191_1' class='gform-field-label gform-field-label--type-inline'>Haute<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_191_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.2' type='checkbox'  value='Basse'  id='choice_11_191_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_191_2' id='label_11_191_2' class='gform-field-label gform-field-label--type-inline'>Basse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_191_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.3' type='checkbox'  value='Non'  id='choice_11_191_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_191_3' id='label_11_191_3' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Cholest\u00e9rol<\/div><fieldset id=\"field_11_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' >Cholest\u00e9rol<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_11_189'><div class='gchoice gchoice_11_189_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.1' type='checkbox'  value='Oui'  id='choice_11_189_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_189_1' id='label_11_189_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_189_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.2' type='checkbox'  value='Non'  id='choice_11_189_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_189_2' id='label_11_189_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Accident vasculaire c\u00e9r\u00e9bral<\/div><fieldset id=\"field_11_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' >Accident vasculaire c\u00e9r\u00e9bral<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_11_195'><div class='gchoice gchoice_11_195_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.1' type='checkbox'  value='Oui'  id='choice_11_195_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_195_1' id='label_11_195_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_195_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.2' type='checkbox'  value='Non'  id='choice_11_195_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_195_2' id='label_11_195_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >\u00c9pilepsie<\/div><fieldset id=\"field_11_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' >\u00c9pilepsie<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_11_193'><div class='gchoice gchoice_11_193_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.1' type='checkbox'  value='Oui'  id='choice_11_193_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_193_1' id='label_11_193_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_193_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.2' type='checkbox'  value='Non'  id='choice_11_193_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_193_2' id='label_11_193_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles \/ maladies syst\u00e8mes nerveux<\/div><fieldset id=\"field_11_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' >Troubles \/ maladies syst\u00e8mes nerveux<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_11_197'><div class='gchoice gchoice_11_197_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.1' type='checkbox'  value='Oui'  id='choice_11_197_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_197_1' id='label_11_197_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_197_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.2' type='checkbox'  value='Non'  id='choice_11_197_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_197_2' id='label_11_197_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles \/ maladies psychiatriques<\/div><fieldset id=\"field_11_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_11_199'><div class='gchoice gchoice_11_199_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.1' type='checkbox'  value='Oui'  id='choice_11_199_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_199_1' id='label_11_199_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_199_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.2' type='checkbox'  value='Non'  id='choice_11_199_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_199_2' id='label_11_199_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >\u00c9tourdissement, \u00e9vanouissement<\/div><fieldset id=\"field_11_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' >\u00c9tourdissement, \u00e9vanouissement<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_11_209'><div class='gchoice gchoice_11_209_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.1' type='checkbox'  value='Oui'  id='choice_11_209_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_209_1' id='label_11_209_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_209_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.2' type='checkbox'  value='Non'  id='choice_11_209_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_209_2' id='label_11_209_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Rhumes fr\u00e9quents ou sinusite<\/div><fieldset id=\"field_11_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' >Rhumes fr\u00e9quents ou sinusite<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_11_211'><div class='gchoice gchoice_11_211_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.1' type='checkbox'  value='Oui'  id='choice_11_211_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_211_1' id='label_11_211_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_211_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.2' type='checkbox'  value='Non'  id='choice_11_211_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_211_2' id='label_11_211_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Maux de t\u00eate fr\u00e9quents<\/div><fieldset id=\"field_11_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' >Maux de t\u00eate fr\u00e9quents<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_11_213'><div class='gchoice gchoice_11_213_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.1' type='checkbox'  value='Oui'  id='choice_11_213_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_213_1' id='label_11_213_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_213_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.2' type='checkbox'  value='Non'  id='choice_11_213_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_213_2' id='label_11_213_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Tuberculose \/ probl\u00e8mes pulmonaires<\/div><fieldset id=\"field_11_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' >Tuberculose \/ probl\u00e8mes pulmonaires<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_11_215'><div class='gchoice gchoice_11_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Oui'  id='choice_11_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_215_1' id='label_11_215_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='Non'  id='choice_11_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_215_2' id='label_11_215_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Probl\u00e8me de foie (h\u00e9patite A, B, C, cirrhose, etc.)<\/div><fieldset id=\"field_11_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' >Probl\u00e8me de foie (h\u00e9patite A, B, C, cirrhose, 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_11_217'><div class='gchoice gchoice_11_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Oui'  id='choice_11_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_217_1' id='label_11_217_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='Non'  id='choice_11_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_217_2' id='label_11_217_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Asthme<\/div><fieldset id=\"field_11_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' >Asthme<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_11_219'><div class='gchoice gchoice_11_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Oui'  id='choice_11_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_219_1' id='label_11_219_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Non'  id='choice_11_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_219_2' id='label_11_219_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles ou maladies du syst\u00e8me digestif<\/div><fieldset id=\"field_11_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' >Troubles ou maladies du syst\u00e8me digestif<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_11_223'><div class='gchoice gchoice_11_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Oui'  id='choice_11_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_223_1' id='label_11_223_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='Non'  id='choice_11_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_223_2' id='label_11_223_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Rhume des foins \/ allergies saisonni\u00e8res<\/div><fieldset id=\"field_11_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' >Rhume des foins \/ allergies saisonni\u00e8res<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_11_221'><div class='gchoice gchoice_11_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Oui'  id='choice_11_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_221_1' id='label_11_221_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='Non'  id='choice_11_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_221_2' id='label_11_221_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles d'estomac (Ulc\u00e8re ou reflux)<\/div><fieldset id=\"field_11_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' >Troubles d&#039;estomac (Ulc\u00e8re ou 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_11_227'><div class='gchoice gchoice_11_227_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.1' type='checkbox'  value='Oui'  id='choice_11_227_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_227_1' id='label_11_227_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_227_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.2' type='checkbox'  value='Non'  id='choice_11_227_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_227_2' id='label_11_227_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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 (tumeur)<\/div><fieldset id=\"field_11_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 (tumeur)<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_11_225'><div class='gchoice gchoice_11_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Oui'  id='choice_11_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_225_1' id='label_11_225_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='Non'  id='choice_11_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_225_2' id='label_11_225_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Radioth\u00e9rapie<\/div><fieldset id=\"field_11_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' >Radioth\u00e9rapie<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_11_231'><div class='gchoice gchoice_11_231_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.1' type='checkbox'  value='Oui'  id='choice_11_231_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_231_1' id='label_11_231_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_231_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_231.2' type='checkbox'  value='Non'  id='choice_11_231_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_231_2' id='label_11_231_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Chimioth\u00e9rapie<\/div><fieldset id=\"field_11_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' >Chimioth\u00e9rapie<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_11_229'><div class='gchoice gchoice_11_229_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.1' type='checkbox'  value='Oui'  id='choice_11_229_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_229_1' id='label_11_229_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_229_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.2' type='checkbox'  value='Non'  id='choice_11_229_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_229_2' id='label_11_229_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles ou maladies du rein<\/div><fieldset id=\"field_11_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' >Troubles ou maladies du rein<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_11_235'><div class='gchoice gchoice_11_235_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.1' type='checkbox'  value='Oui'  id='choice_11_235_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_235_1' id='label_11_235_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_235_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.2' type='checkbox'  value='Non'  id='choice_11_235_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_235_2' id='label_11_235_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Diab\u00e8te (Type 1 ou 2)<\/div><fieldset id=\"field_11_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' >Diab\u00e8te (Type 1 ou 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_11_233'><div class='gchoice gchoice_11_233_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_233.1' type='checkbox'  value='Oui'  id='choice_11_233_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_233_1' id='label_11_233_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_233_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_233.2' type='checkbox'  value='Non'  id='choice_11_233_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_233_2' id='label_11_233_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Troubles thyro\u00efdiens (Hyper ou hypo)<\/div><fieldset id=\"field_11_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' >Troubles thyro\u00efdiens (Hyper ou 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_11_239'><div class='gchoice gchoice_11_239_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.1' type='checkbox'  value='Oui'  id='choice_11_239_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_239_1' id='label_11_239_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_239_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.2' type='checkbox'  value='Non'  id='choice_11_239_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_239_2' id='label_11_239_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Anxi\u00e9t\u00e9<\/div><fieldset id=\"field_11_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' >Anxi\u00e9t\u00e9<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_11_237'><div class='gchoice gchoice_11_237_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.1' type='checkbox'  value='Oui'  id='choice_11_237_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_237_1' id='label_11_237_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_237_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.2' type='checkbox'  value='Non'  id='choice_11_237_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_237_2' id='label_11_237_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Remplacement d'articulation (genou\/hanche)<\/div><fieldset id=\"field_11_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' >Remplacement d&#039;articulation (genou\/hanche)<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_11_243'><div class='gchoice gchoice_11_243_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_243.1' type='checkbox'  value='Oui'  id='choice_11_243_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_243_1' id='label_11_243_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_243_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_243.2' type='checkbox'  value='Non'  id='choice_11_243_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_243_2' id='label_11_243_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Transplantation d'organe \/ implant m\u00e9dical<\/div><fieldset id=\"field_11_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' >Transplantation d&#039;organe \/ implant m\u00e9dical<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_11_241'><div class='gchoice gchoice_11_241_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.1' type='checkbox'  value='Oui'  id='choice_11_241_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_241_1' id='label_11_241_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_241_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.2' type='checkbox'  value='Non'  id='choice_11_241_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_241_2' id='label_11_241_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Infection transmissibles sexuellement et par le sang (ITSS)<\/div><fieldset id=\"field_11_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' >Infection transmissibles sexuellement et par le sang (ITSS)<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_11_247'><div class='gchoice gchoice_11_247_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_247.1' type='checkbox'  value='Oui'  id='choice_11_247_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_247_1' id='label_11_247_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_247_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_247.2' type='checkbox'  value='Non'  id='choice_11_247_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_247_2' id='label_11_247_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >\u00cates-vous s\u00e9ropositif?<\/div><fieldset id=\"field_11_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' >\u00cates-vous s\u00e9ropositif?<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_11_245'><div class='gchoice gchoice_11_245_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_245.1' type='checkbox'  value='Oui'  id='choice_11_245_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_245_1' id='label_11_245_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_245_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_245.2' type='checkbox'  value='Non'  id='choice_11_245_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_245_2' id='label_11_245_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Toxicomanie<\/div><fieldset id=\"field_11_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' >Toxicomanie<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_11_251'><div class='gchoice gchoice_11_251_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.1' type='checkbox'  value='Oui'  id='choice_11_251_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_251_1' id='label_11_251_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_251_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.2' type='checkbox'  value='Non'  id='choice_11_251_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_251_2' id='label_11_251_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Consommez-vous des drogues<\/div><fieldset id=\"field_11_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' >Consommez-vous des drogues<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_11_249'><div class='gchoice gchoice_11_249_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_249.1' type='checkbox'  value='Oui'  id='choice_11_249_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_249_1' id='label_11_249_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_249_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_249.2' type='checkbox'  value='Non'  id='choice_11_249_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_249_2' id='label_11_249_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_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' >Y a t-il une maladie, un \u00e9tat physique ou probl\u00e8me qui n\u2019est pas ci-dessus et que nous devrions savoir?<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_11_252'><div class='gchoice gchoice_11_252_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_252.1' type='checkbox'  value='Oui'  id='choice_11_252_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_252_1' id='label_11_252_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_252_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_252.2' type='checkbox'  value='Non'  id='choice_11_252_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_252_2' id='label_11_252_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_83'>Si oui, pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_11_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >Fumez-vous?<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_11_255'><div class='gchoice gchoice_11_255_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.1' type='checkbox'  value='Oui - Cigarette'  id='choice_11_255_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_255_1' id='label_11_255_1' class='gform-field-label gform-field-label--type-inline'>Oui - Cigarette<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_255_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.2' type='checkbox'  value='Oui - Canabis'  id='choice_11_255_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_255_2' id='label_11_255_2' class='gform-field-label gform-field-label--type-inline'>Oui - Canabis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_255_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.3' type='checkbox'  value='Oui- Vapotage'  id='choice_11_255_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_255_3' id='label_11_255_3' class='gform-field-label gform-field-label--type-inline'>Oui- Vapotage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_255_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_255.4' type='checkbox'  value='Non'  id='choice_11_255_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_255_4' id='label_11_255_4' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_256'>Si oui, cig.\/jour et nb. ann\u00e9es<\/label><div class='ginput_container ginput_container_text'><input name='input_256' id='input_11_256' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >Consommez-vous de l&#039;alcool ?<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_11_257'><div class='gchoice gchoice_11_257_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.1' type='checkbox'  value='Oui'  id='choice_11_257_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_257_1' id='label_11_257_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_257_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.2' type='checkbox'  value='Non'  id='choice_11_257_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_257_2' id='label_11_257_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_258'>Fr\u00e9quence<\/label><div class='ginput_container ginput_container_text'><input name='input_258' id='input_11_258' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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>Femme seulement<\/strong><\/span><\/div><fieldset id=\"field_11_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' >\u00cates-vous enceinte?<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_11_260'><div class='gchoice gchoice_11_260_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.1' type='checkbox'  value='Oui'  id='choice_11_260_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_260_1' id='label_11_260_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_260_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.2' type='checkbox'  value='Non'  id='choice_11_260_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_260_2' id='label_11_260_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_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' >Allaitez-vous?<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_11_262'><div class='gchoice gchoice_11_262_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.1' type='checkbox'  value='Oui'  id='choice_11_262_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_262_1' id='label_11_262_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_262_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.2' type='checkbox'  value='Non'  id='choice_11_262_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_262_2' id='label_11_262_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_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' >Pilule anticonceptionnelle?<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_11_263'><div class='gchoice gchoice_11_263_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.1' type='checkbox'  value='Oui'  id='choice_11_263_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_263_1' id='label_11_263_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_263_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.2' type='checkbox'  value='Non'  id='choice_11_263_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_263_2' id='label_11_263_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_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;\">HISTOIRE DENTAIRE<\/div><\/div><div id=\"field_11_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. Veuillez cocher OUI ou NON \u00e0 chacune des questions:<\/style><\/div><div id=\"field_11_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\"  >Vos gencives saignent-elles?<\/div><fieldset id=\"field_11_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' >Vos gencives saignent-elles?<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_11_268'><div class='gchoice gchoice_11_268_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_268.1' type='checkbox'  value='Oui'  id='choice_11_268_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_268_1' id='label_11_268_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_268_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_268.2' type='checkbox'  value='Non'  id='choice_11_268_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_268_2' id='label_11_268_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Est-ce que parfois votre haleine vous g\u00eane?<\/div><fieldset id=\"field_11_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' >Est-ce que parfois votre haleine vous g\u00eane?<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_11_271'><div class='gchoice gchoice_11_271_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_271.1' type='checkbox'  value='Oui'  id='choice_11_271_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_271_1' id='label_11_271_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_271_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_271.2' type='checkbox'  value='Non'  id='choice_11_271_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_271_2' id='label_11_271_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Grincez ou serrez-vous des dents le jour ou la nuit?<\/div><fieldset id=\"field_11_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' >Grincez ou serrez-vous des dents le jour ou la nuit?<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_11_276'><div class='gchoice gchoice_11_276_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_276.1' type='checkbox'  value='Oui'  id='choice_11_276_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_276_1' id='label_11_276_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_276_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_276.2' type='checkbox'  value='Non'  id='choice_11_276_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_276_2' id='label_11_276_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Est-ce que vos dents sont sensibles?<\/div><fieldset id=\"field_11_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' >Est-ce que vos dents sont sensibles?<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_11_274'><div class='gchoice gchoice_11_274_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_274.1' type='checkbox'  value='Oui'  id='choice_11_274_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_274_1' id='label_11_274_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_274_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_274.2' type='checkbox'  value='Non'  id='choice_11_274_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_274_2' id='label_11_274_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Est-ce que vos dents se d\u00e9chaussent?<\/div><fieldset id=\"field_11_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' >Est-ce que vos dents se d\u00e9chaussent?<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_11_280'><div class='gchoice gchoice_11_280_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_280.1' type='checkbox'  value='Oui'  id='choice_11_280_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_280_1' id='label_11_280_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_280_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_280.2' type='checkbox'  value='Non'  id='choice_11_280_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_280_2' id='label_11_280_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Avez-vous not\u00e9 un d\u00e9placement de vos dents?<\/div><fieldset id=\"field_11_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' >Avez-vous not\u00e9 un d\u00e9placement de vos dents?<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_11_278'><div class='gchoice gchoice_11_278_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_278.1' type='checkbox'  value='Oui'  id='choice_11_278_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_278_1' id='label_11_278_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_278_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_278.2' type='checkbox'  value='Non'  id='choice_11_278_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_278_2' id='label_11_278_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Sentez-vous que vos dents bougent?<\/div><fieldset id=\"field_11_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' >Sentez-vous que vos dents bougent?<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_11_284'><div class='gchoice gchoice_11_284_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_284.1' type='checkbox'  value='Oui'  id='choice_11_284_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_284_1' id='label_11_284_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_284_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_284.2' type='checkbox'  value='Non'  id='choice_11_284_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_284_2' id='label_11_284_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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\"  >Est-ce que la nourriture reste coinc\u00e9e entre vos dents?<\/div><fieldset id=\"field_11_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' >Est-ce que la nourriture reste coinc\u00e9e entre vos dents?<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_11_282'><div class='gchoice gchoice_11_282_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_282.1' type='checkbox'  value='Oui'  id='choice_11_282_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_282_1' id='label_11_282_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_282_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_282.2' type='checkbox'  value='Non'  id='choice_11_282_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_282_2' id='label_11_282_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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. A quelle fr\u00e9quence visitez-vous votre dentiste?<\/style><\/div><fieldset id=\"field_11_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. 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_11_286'><div class='gchoice gchoice_11_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 mois'  id='choice_11_286_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_1' id='label_11_286_1' class='gform-field-label gform-field-label--type-inline'>3-4 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_286_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.2' type='checkbox'  value='6 mois'  id='choice_11_286_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_2' id='label_11_286_2' class='gform-field-label gform-field-label--type-inline'>6 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_286_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.3' type='checkbox'  value='9 mois'  id='choice_11_286_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_3' id='label_11_286_3' class='gform-field-label gform-field-label--type-inline'>9 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_286_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.4' type='checkbox'  value='12 mois'  id='choice_11_286_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_4' id='label_11_286_4' class='gform-field-label gform-field-label--type-inline'>12 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_286_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.5' type='checkbox'  value='irr\u00e9guli\u00e8rement'  id='choice_11_286_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_5' id='label_11_286_5' class='gform-field-label gform-field-label--type-inline'>irr\u00e9guli\u00e8rement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_286_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.6' type='checkbox'  value='autre'  id='choice_11_286_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_286_6' id='label_11_286_6' class='gform-field-label gform-field-label--type-inline'>autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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_11_287'>Derni\u00e8re visite:<\/label><div class='ginput_container ginput_container_text'><input name='input_287' id='input_11_287' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_288'>Raison de la visite:<\/label><div class='ginput_container ginput_container_text'><input name='input_288' id='input_11_288' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_289'>Dernier nettoyage:<\/label><div class='ginput_container ginput_container_text'><input name='input_289' id='input_11_289' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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. Avez-vous d\u00e9j\u00e0 eu? (s.v.p. cocher):<\/style><\/div><fieldset id=\"field_11_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_11_291'><div class='gchoice gchoice_11_291_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.1' type='checkbox'  value='Chirurgie buccale'  id='choice_11_291_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_291_1' id='label_11_291_1' class='gform-field-label gform-field-label--type-inline'>Chirurgie buccale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_291_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.2' type='checkbox'  value='Traitement parodontal'  id='choice_11_291_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_291_2' id='label_11_291_2' class='gform-field-label gform-field-label--type-inline'>Traitement parodontal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_291_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.3' type='checkbox'  value='Traitement d&#039;orthodontie'  id='choice_11_291_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_291_3' id='label_11_291_3' class='gform-field-label gform-field-label--type-inline'>Traitement d'orthodontie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_291_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.4' type='checkbox'  value='Plaque occlusale'  id='choice_11_291_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_291_4' id='label_11_291_4' class='gform-field-label gform-field-label--type-inline'>Plaque occlusale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_291_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.5' type='checkbox'  value='Autre appareil'  id='choice_11_291_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_291_5' id='label_11_291_5' class='gform-field-label gform-field-label--type-inline'>Autre appareil<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_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;\">ACCEPTATION<\/div><\/div><fieldset id=\"field_11_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation historique m\u00e9dicale<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_11_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_11_88_1' >Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dicodentaire au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.  J\u2019autorise la constitution de mon dossier dentaire, son suivi, ainsi que mon inscription sur la liste de rappel de Parodontie Rockland. On m\u2019a inform\u00e9 que mon dossier sera conserv\u00e9 au cabinet et que seul le parodontiste et ses employ\u00e9s y auront acc\u00e8s. On m\u2019a inform\u00e9 de mon droit de consulter mon dossier, d\u2019y demander une rectification et de me retirer de la liste de rappel.<\/label><input type='hidden' name='input_88.2' value='Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dicodentaire au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.  J\u2019autorise la constitution de mon dossier dentaire, son suivi, ainsi que mon inscription sur la liste de rappel de Parodontie Rockland. On m\u2019a inform\u00e9 que mon dossier sera conserv\u00e9 au cabinet et que seul le parodontiste et ses employ\u00e9s y auront acc\u00e8s. On m\u2019a inform\u00e9 de mon droit de consulter mon dossier, d\u2019y demander une rectification et de me retirer de la liste de rappel.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='5' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_90\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation historique dentaire<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_11_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_11_90_1' >Je, soussign\u00e9, d\u00e9clare avoir r\u00e9pondu \u00e0 ce questionnaire au meilleur de ma connaissance et m\u2019\u00eatre renseign\u00e9 aupr\u00e8s de mon parodontiste si certains points n\u2019\u00e9taient pas clairs. Je comprends que le but de ce questionnaire est de parvenir aux meilleurs r\u00e9sultats possible.<\/label><input type='hidden' name='input_90.2' value='Je, soussign\u00e9, d\u00e9clare avoir r\u00e9pondu \u00e0 ce questionnaire au meilleur de ma connaissance et m\u2019\u00eatre renseign\u00e9 aupr\u00e8s de mon parodontiste si certains points n\u2019\u00e9taient pas clairs. Je comprends que le but de ce questionnaire est de parvenir aux meilleurs r\u00e9sultats possible.' class='gform_hidden' \/><input type='hidden' name='input_90.3' value='5' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_303\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Acceptation collecte d&#039;informations personnelles*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_303.1' id='input_11_303_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_11_303\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_11_303_1' >Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l'utilisation et \u00e0 la divulgation de mes renseignements personnels par PARODONTIE ROCKLAND dans le but de fournir des services dentaires.<\/label><input type='hidden' name='input_303.2' value='Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l&#039;utilisation et \u00e0 la divulgation de mes renseignements personnels par PARODONTIE ROCKLAND dans le but de fournir des services dentaires.' class='gform_hidden' \/><input type='hidden' name='input_303.3' value='5' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_11_303' tabindex='0'>En savoir plus sur notre <a href=\"https:\/\/parodontierockland.com\/politique-de-confidentialite\/\" target=\"_blank\">Politique de confidentialit\u00e9<\/a><\/div><\/fieldset><div id=\"field_11_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_11_2'>Signature du patient ou du responsable<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_11_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_11_2_valid' id='input_11_2_valid' \/><canvas id='input_11_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #ab004f; background-color:#ebebeb; cursor: url(https:\/\/parodontierockland.com\/qm-fr\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_11_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_11_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_11_2_data' name='input_11_2_data' value=''><\/div><\/div><div id=\"field_11_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_11_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_11_33' type='text' value='20 May 2026 20h36' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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_11_124'><div class='gchoice gchoice_11_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_11_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_124_1' id='label_11_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_11_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_11_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_124_2' id='label_11_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_11_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;\">** R\u00c9SERV\u00c9 \u00c0 L'ADMINISTRATION**<\/div><\/div><div id=\"field_11_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_11_112'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_11_112' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_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_11_113'>Pr\u00e9cautions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_11_113' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_11_111\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Acceptation du sp\u00e9cialiste<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_11_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_11_111_1' >Je reconnais avoir pris connaissance des r\u00e9ponses au questionnaire d\u2019inscription et avoir pris les mesures d\u2019usage, le cas \u00e9ch\u00e9ant.<\/label><input type='hidden' name='input_111.2' value='Je reconnais avoir pris connaissance des r\u00e9ponses au questionnaire d\u2019inscription et avoir pris les mesures d\u2019usage, le cas \u00e9ch\u00e9ant.' class='gform_hidden' \/><input type='hidden' name='input_111.3' value='5' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_11_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_11_117'>Signature du sp\u00e9cialiste<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_11_117_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_11_117_valid' id='input_11_117_valid' \/><canvas id='input_11_117' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #545454; background-color:#ebebeb; cursor: url(https:\/\/parodontierockland.com\/qm-fr\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_11_117_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_11_117_resetbutton' 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