{"id":33652,"date":"2024-05-23T14:52:40","date_gmt":"2024-05-23T18:52:40","guid":{"rendered":"https:\/\/cdleblainvillier.com\/questionnnaire-medical\/"},"modified":"2024-05-24T10:13:10","modified_gmt":"2024-05-24T14:13:10","slug":"questionnnaire-medical","status":"publish","type":"page","link":"https:\/\/cdleblainvillier.com\/en\/questionnnaire-medical\/","title":{"rendered":"Medical questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"33652\" class=\"elementor elementor-33652 elementor-33023\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8bc31ff e-con-full e-flex cmsmasters-bg-hide-none cmsmasters-bg-hide-none cmsmasters-block-default e-con e-parent\" data-id=\"8bc31ff\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-b3d6e20 e-con-full e-flex cmsmasters-block-default e-con e-child\" data-id=\"b3d6e20\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8c840f6 elementor-absolute cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-image\" data-id=\"8c840f6\" data-element_type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"50\" height=\"50\" src=\"https:\/\/cdleblainvillier.com\/wp-content\/uploads\/2024\/02\/triangle.svg\" class=\"attachment-full size-full wp-image-33267\" alt=\"Triangle\">\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-22dd903 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-heading\" data-id=\"22dd903\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Medical questionnaire<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1061860 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-text-editor\" data-id=\"1061860\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p>New patient? You must complete a form regarding the details of your state of health before your first appointment at the clinic. We invite you to complete the form below.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cffa170 elementor-absolute cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-image\" data-id=\"cffa170\" data-element_type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"50\" height=\"50\" src=\"https:\/\/cdleblainvillier.com\/wp-content\/uploads\/2024\/02\/triangle.svg\" class=\"attachment-full size-full wp-image-33267\" alt=\"Triangle\">\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8d82f05 e-con-full e-flex cmsmasters-block-default e-con e-parent\" data-id=\"8d82f05\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element 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class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_258\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_258'>Comments<\/label><div class='ginput_container'><input name='input_258' id='input_6_258' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_258'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_6_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATIONS<\/div><\/li><li id=\"field_6_173\" class=\"gfield gfield--type-text gfield--input-type-text rougerouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_173'>* Veuillez porter attention<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_6_173' type='text' value='* OUI * ' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_11\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_175\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_175'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_6_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_6_35' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_6_35_2_container'><label for='input_6_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_6_35_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_6_35_1_container'><label for='input_6_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_6_35_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_6_35_3_container'><label for='input_6_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_6_35_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_13'>\n\t\t\t<li class='gchoice gchoice_6_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='M'  id='choice_6_13_0'    \/>\n\t\t\t\t<label for='choice_6_13_0' id='label_6_13_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='F'  id='choice_6_13_1'    \/>\n\t\t\t\t<label for='choice_6_13_1' id='label_6_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Other'  id='choice_6_13_2'    \/>\n\t\t\t\t<label for='choice_6_13_2' id='label_6_13_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_123\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_123'>Health Ins. No.<\/label><div class='gfield_description' id='gfield_description_6_123'>(To be completed for children aged 10 and under)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_6_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_6_123\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_254\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_254'>Expiration<\/label><div class='gfield_description' id='gfield_description_6_254'>(MM\/YYYY)<\/div><div class='ginput_container ginput_container_text'><input name='input_254' id='input_6_254' type='text' value='' class='medium'  aria-describedby=\"gfield_description_6_254\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_36'>Home Tel.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_6_36' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_38'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_6_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_37\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_6_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_34\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_6_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_34_1' id='input_6_34_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_6_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_34_3' id='input_6_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_34_4_container' >\n                                        <select name='input_34.4' id='input_6_34_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_6_34_4' id='input_6_34_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_6_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_34_5' id='input_6_34_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_6_34_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you under 18?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_126'>\n\t\t\t<li class='gchoice gchoice_6_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_6_126_0'    \/>\n\t\t\t\t<label for='choice_6_126_0' id='label_6_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_6_126_1'    \/>\n\t\t\t\t<label for='choice_6_126_1' id='label_6_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_46\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>Father&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_127\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_127'>Home Tel.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_127' id='input_6_127' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_128\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_128'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_6_128' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_129\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_129'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_6_129' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_130\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_130'>Mother&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_6_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_133\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'>Home Tel.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_133' id='input_6_133' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_132\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_132'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_6_132' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_131\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_131'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_6_131' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Who is responsible for the fees?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_134'>\n\t\t\t<li class='gchoice gchoice_6_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Father'  id='choice_6_134_0'    \/>\n\t\t\t\t<label for='choice_6_134_0' id='label_6_134_0' class='gform-field-label gform-field-label--type-inline'>Father<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Mother'  id='choice_6_134_1'    \/>\n\t\t\t\t<label for='choice_6_134_1' id='label_6_134_1' class='gform-field-label gform-field-label--type-inline'>Mother<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_134_2'>\n\t\t\t\t<input name='input_134' type='radio' value='Other'  id='choice_6_134_2'    \/>\n\t\t\t\t<label for='choice_6_134_2' id='label_6_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_47\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_47'>Specify Other<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_6_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_40\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_40'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_6_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_179\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >For emergencies, call:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name no_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_179'>\n                            \n                            <span id='input_6_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_6_179_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_179_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            <span id='input_6_179_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.4' id='input_6_179_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_179_4' class='gform-field-label gform-field-label--type-sub '>Relationship to patient<\/label>\n                                                <\/span>\n                            \n                            \n                        <\/div><\/li><li id=\"field_6_180\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_180'>Main Tel.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_180' id='input_6_180' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_181\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_181'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_181' id='input_6_181' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL INFORMATION<\/div><\/li><li id=\"field_6_139\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_139'>Reason for today\u2019s visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_6_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Last visit :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_15'>\n\t\t\t<li class='gchoice gchoice_6_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='0-6 month'  id='choice_6_15_0'    \/>\n\t\t\t\t<label for='choice_6_15_0' id='label_6_15_0' class='gform-field-label gform-field-label--type-inline'>0-6 month<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='6-12 month'  id='choice_6_15_1'    \/>\n\t\t\t\t<label for='choice_6_15_1' id='label_6_15_1' class='gform-field-label gform-field-label--type-inline'>6-12 month<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='+12 month'  id='choice_6_15_2'    \/>\n\t\t\t\t<label for='choice_6_15_2' id='label_6_15_2' class='gform-field-label gform-field-label--type-inline'>+12 month<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_182\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_182'>Treatment(s) received<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_6_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >With panoramic radiographs (large x-ray)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_142'>\n\t\t\t<li class='gchoice gchoice_6_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_6_142_0'    \/>\n\t\t\t\t<label for='choice_6_142_0' id='label_6_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_6_142_1'    \/>\n\t\t\t\t<label for='choice_6_142_1' id='label_6_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >With intraoral radiographs (small x-rays)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_143'>\n\t\t\t<li class='gchoice gchoice_6_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_6_143_0'    \/>\n\t\t\t\t<label for='choice_6_143_0' id='label_6_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_6_143_1'    \/>\n\t\t\t\t<label for='choice_6_143_1' id='label_6_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you fear dental treatments?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_145'>\n\t\t\t<li class='gchoice gchoice_6_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Not at all'  id='choice_6_145_0'    \/>\n\t\t\t\t<label for='choice_6_145_0' id='label_6_145_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='A little'  id='choice_6_145_1'    \/>\n\t\t\t\t<label for='choice_6_145_1' id='label_6_145_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_145_2'>\n\t\t\t\t<input name='input_145' type='radio' value='Very much'  id='choice_6_145_2'    \/>\n\t\t\t\t<label for='choice_6_145_2' id='label_6_145_2' class='gform-field-label gform-field-label--type-inline'>Very much<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_136\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_136'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_6_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Would you like to speak privately with your dentist?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_183'>\n\t\t\t<li class='gchoice gchoice_6_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='Yes'  id='choice_6_183_0'    \/>\n\t\t\t\t<label for='choice_6_183_0' id='label_6_183_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_6_183_1'    \/>\n\t\t\t\t<label for='choice_6_183_1' id='label_6_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_184\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_184'>Reason, details and date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_6_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you being treated by a physician?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_185'>\n\t\t\t<li class='gchoice gchoice_6_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='Yes'  id='choice_6_185_0'    \/>\n\t\t\t\t<label for='choice_6_185_0' id='label_6_185_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_6_185_1'    \/>\n\t\t\t\t<label for='choice_6_185_1' id='label_6_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_186\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_186'>Physician&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_6_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_256\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_256'>Physician Tel.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_256' id='input_6_256' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_255\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_255'>Reason, details and date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_6_255' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had surgery or been hospitalized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_187'>\n\t\t\t<li class='gchoice gchoice_6_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='Yes'  id='choice_6_187_0'    \/>\n\t\t\t\t<label for='choice_6_187_0' id='label_6_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_6_187_1'    \/>\n\t\t\t\t<label for='choice_6_187_1' id='label_6_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_188\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_188'>Reason, details and date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_6_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have joint prostheses (hip, knee, etc.)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_189'>\n\t\t\t<li class='gchoice gchoice_6_189_0'>\n\t\t\t\t<input name='input_189' type='radio' value='Yes'  id='choice_6_189_0'    \/>\n\t\t\t\t<label for='choice_6_189_0' id='label_6_189_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_189_1'>\n\t\t\t\t<input name='input_189' type='radio' value='No'  id='choice_6_189_1'    \/>\n\t\t\t\t<label for='choice_6_189_1' id='label_6_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_190\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_190'>Reason, details and date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_6_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_191\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you gained or lost a lot of weight recently?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_191'>\n\t\t\t<li class='gchoice gchoice_6_191_0'>\n\t\t\t\t<input name='input_191' type='radio' value='Yes'  id='choice_6_191_0'    \/>\n\t\t\t\t<label for='choice_6_191_0' id='label_6_191_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_191_1'>\n\t\t\t\t<input name='input_191' type='radio' value='No'  id='choice_6_191_1'    \/>\n\t\t\t\t<label for='choice_6_191_1' id='label_6_191_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_192\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_192'>Reason, details and date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_6_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you taking natural or homeopathic products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_193'>\n\t\t\t<li class='gchoice gchoice_6_193_0'>\n\t\t\t\t<input name='input_193' type='radio' value='Yes'  id='choice_6_193_0'    \/>\n\t\t\t\t<label for='choice_6_193_0' id='label_6_193_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_193_1'>\n\t\t\t\t<input name='input_193' type='radio' value='No'  id='choice_6_193_1'    \/>\n\t\t\t\t<label for='choice_6_193_1' id='label_6_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_194\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_194'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_6_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_195'>\n\t\t\t<li class='gchoice gchoice_6_195_0'>\n\t\t\t\t<input name='input_195' type='radio' value='Yes'  id='choice_6_195_0'    \/>\n\t\t\t\t<label for='choice_6_195_0' id='label_6_195_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_195_1'>\n\t\t\t\t<input name='input_195' type='radio' value='No'  id='choice_6_195_1'    \/>\n\t\t\t\t<label for='choice_6_195_1' id='label_6_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you breastfeeding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_196'>\n\t\t\t<li class='gchoice gchoice_6_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='Yes'  id='choice_6_196_0'    \/>\n\t\t\t\t<label for='choice_6_196_0' id='label_6_196_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='No'  id='choice_6_196_1'    \/>\n\t\t\t\t<label for='choice_6_196_1' id='label_6_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_197\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you taking medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_197'>\n\t\t\t<li class='gchoice gchoice_6_197_0'>\n\t\t\t\t<input name='input_197' type='radio' value='Yes'  id='choice_6_197_0'    \/>\n\t\t\t\t<label for='choice_6_197_0' id='label_6_197_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_197_1'>\n\t\t\t\t<input name='input_197' type='radio' value='No'  id='choice_6_197_1'    \/>\n\t\t\t\t<label for='choice_6_197_1' id='label_6_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you taking birth control or hormones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_198'>\n\t\t\t<li class='gchoice gchoice_6_198_0'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes birth control'  id='choice_6_198_0'    \/>\n\t\t\t\t<label for='choice_6_198_0' id='label_6_198_0' class='gform-field-label gform-field-label--type-inline'>Yes birth control<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_198_1'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes hormones'  id='choice_6_198_1'    \/>\n\t\t\t\t<label for='choice_6_198_1' id='label_6_198_1' class='gform-field-label gform-field-label--type-inline'>Yes hormones<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_198_2'>\n\t\t\t\t<input name='input_198' type='radio' value='No'  id='choice_6_198_2'    \/>\n\t\t\t\t<label for='choice_6_198_2' id='label_6_198_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_199'>Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_6_199' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_138\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR CURRENT CONDITION<\/div><\/li><li id=\"field_6_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#000000;color:#ffffff;font-weight:bold;font-size:16px;\">Blood disorders<\/div><\/li><li id=\"field_6_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >(hemophilia, anemia, prolonged bleeding)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_55'>\n\t\t\t<li class='gchoice gchoice_6_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Yes'  id='choice_6_55_0'    \/>\n\t\t\t\t<label for='choice_6_55_0' id='label_6_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_6_55_1'    \/>\n\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#000000;color:#ffffff;font-weight:bold;font-size:16px;\">Heart conditions<\/div><\/li><li id=\"field_6_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infarction (heart attack), angina, surgery, etc.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_54'>\n\t\t\t<li class='gchoice gchoice_6_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_6_54_0'    \/>\n\t\t\t\t<label for='choice_6_54_0' id='label_6_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_6_54_1'    \/>\n\t\t\t\t<label for='choice_6_54_1' id='label_6_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Heart infection (endocarditis)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_202'>\n\t\t\t<li class='gchoice gchoice_6_202_0'>\n\t\t\t\t<input name='input_202' type='radio' value='Yes'  id='choice_6_202_0'    \/>\n\t\t\t\t<label for='choice_6_202_0' id='label_6_202_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_202_1'>\n\t\t\t\t<input name='input_202' type='radio' value='No'  id='choice_6_202_1'    \/>\n\t\t\t\t<label for='choice_6_202_1' id='label_6_202_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_203\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Surgery to replace or repair a valve \/cusp<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_203'>\n\t\t\t<li class='gchoice gchoice_6_203_0'>\n\t\t\t\t<input name='input_203' type='radio' value='Yes'  id='choice_6_203_0'    \/>\n\t\t\t\t<label for='choice_6_203_0' id='label_6_203_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_203_1'>\n\t\t\t\t<input name='input_203' type='radio' value='No'  id='choice_6_203_1'    \/>\n\t\t\t\t<label for='choice_6_203_1' id='label_6_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_204\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#000000;color:#ffffff;font-weight:bold;font-size:16px;\">Other<\/div><\/li><li id=\"field_6_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_57'>\n\t\t\t<li class='gchoice gchoice_6_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - Low'  id='choice_6_57_0'    \/>\n\t\t\t\t<label for='choice_6_57_0' id='label_6_57_0' class='gform-field-label gform-field-label--type-inline'>Yes - Low<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - High'  id='choice_6_57_1'    \/>\n\t\t\t\t<label for='choice_6_57_1' id='label_6_57_1' class='gform-field-label gform-field-label--type-inline'>Yes - High<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_6_57_2'    \/>\n\t\t\t\t<label for='choice_6_57_2' id='label_6_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dizziness, fainting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_205'>\n\t\t\t<li class='gchoice gchoice_6_205_0'>\n\t\t\t\t<input name='input_205' type='radio' value='Yes'  id='choice_6_205_0'    \/>\n\t\t\t\t<label for='choice_6_205_0' id='label_6_205_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_205_1'>\n\t\t\t\t<input name='input_205' type='radio' value='No'  id='choice_6_205_1'    \/>\n\t\t\t\t<label for='choice_6_205_1' id='label_6_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_206'>\n\t\t\t<li class='gchoice gchoice_6_206_0'>\n\t\t\t\t<input name='input_206' type='radio' value='Yes'  id='choice_6_206_0'    \/>\n\t\t\t\t<label for='choice_6_206_0' id='label_6_206_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_206_1'>\n\t\t\t\t<input name='input_206' type='radio' value='No'  id='choice_6_206_1'    \/>\n\t\t\t\t<label for='choice_6_206_1' id='label_6_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_207\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Jaw pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_207'>\n\t\t\t<li class='gchoice gchoice_6_207_0'>\n\t\t\t\t<input name='input_207' type='radio' value='Yes'  id='choice_6_207_0'    \/>\n\t\t\t\t<label for='choice_6_207_0' id='label_6_207_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_207_1'>\n\t\t\t\t<input name='input_207' type='radio' value='No'  id='choice_6_207_1'    \/>\n\t\t\t\t<label for='choice_6_207_1' id='label_6_207_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Liver disorders (hepatitis A, B, C. cirrhosis, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_208'>\n\t\t\t<li class='gchoice gchoice_6_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='Yes'  id='choice_6_208_0'    \/>\n\t\t\t\t<label for='choice_6_208_0' id='label_6_208_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='No'  id='choice_6_208_1'    \/>\n\t\t\t\t<label for='choice_6_208_1' id='label_6_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Digestive system disorders or diseases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_209'>\n\t\t\t<li class='gchoice gchoice_6_209_0'>\n\t\t\t\t<input name='input_209' type='radio' value='Yes'  id='choice_6_209_0'    \/>\n\t\t\t\t<label for='choice_6_209_0' id='label_6_209_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_209_1'>\n\t\t\t\t<input name='input_209' type='radio' value='No'  id='choice_6_209_1'    \/>\n\t\t\t\t<label for='choice_6_209_1' id='label_6_209_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_210\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_210'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_6_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_211\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stomach disorders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_211'>\n\t\t\t<li class='gchoice gchoice_6_211_0'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Ulcer'  id='choice_6_211_0'    \/>\n\t\t\t\t<label for='choice_6_211_0' id='label_6_211_0' class='gform-field-label gform-field-label--type-inline'>Yes, Ulcer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_211_1'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Reflux'  id='choice_6_211_1'    \/>\n\t\t\t\t<label for='choice_6_211_1' id='label_6_211_1' class='gform-field-label gform-field-label--type-inline'>Yes, Reflux<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_211_2'>\n\t\t\t\t<input name='input_211' type='radio' value='No'  id='choice_6_211_2'    \/>\n\t\t\t\t<label for='choice_6_211_2' id='label_6_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_212\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Kidney disorders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_212'>\n\t\t\t<li class='gchoice gchoice_6_212_0'>\n\t\t\t\t<input name='input_212' type='radio' value='Yes'  id='choice_6_212_0'    \/>\n\t\t\t\t<label for='choice_6_212_0' id='label_6_212_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_212_1'>\n\t\t\t\t<input name='input_212' type='radio' value='No'  id='choice_6_212_1'    \/>\n\t\t\t\t<label for='choice_6_212_1' id='label_6_212_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_213\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_213'>\n\t\t\t<li class='gchoice gchoice_6_213_0'>\n\t\t\t\t<input name='input_213' type='radio' value='Yes'  id='choice_6_213_0'    \/>\n\t\t\t\t<label for='choice_6_213_0' id='label_6_213_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_213_1'>\n\t\t\t\t<input name='input_213' type='radio' value='No'  id='choice_6_213_1'    \/>\n\t\t\t\t<label for='choice_6_213_1' id='label_6_213_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_214\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Thyroid disorders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_214'>\n\t\t\t<li class='gchoice gchoice_6_214_0'>\n\t\t\t\t<input name='input_214' type='radio' value='Yes'  id='choice_6_214_0'    \/>\n\t\t\t\t<label for='choice_6_214_0' id='label_6_214_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_214_1'>\n\t\t\t\t<input name='input_214' type='radio' value='No'  id='choice_6_214_1'    \/>\n\t\t\t\t<label for='choice_6_214_1' id='label_6_214_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_217\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Cancer (tumour)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_217'>\n\t\t\t<li class='gchoice gchoice_6_217_0'>\n\t\t\t\t<input name='input_217' type='radio' value='Yes'  id='choice_6_217_0'    \/>\n\t\t\t\t<label for='choice_6_217_0' id='label_6_217_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_217_1'>\n\t\t\t\t<input name='input_217' type='radio' value='No'  id='choice_6_217_1'    \/>\n\t\t\t\t<label for='choice_6_217_1' id='label_6_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_218\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_218'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_6_218' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Radiotherapy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_219'>\n\t\t\t<li class='gchoice gchoice_6_219_0'>\n\t\t\t\t<input name='input_219' type='radio' value='Yes'  id='choice_6_219_0'    \/>\n\t\t\t\t<label for='choice_6_219_0' id='label_6_219_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_219_1'>\n\t\t\t\t<input name='input_219' type='radio' value='No'  id='choice_6_219_1'    \/>\n\t\t\t\t<label for='choice_6_219_1' id='label_6_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_220\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chemotherapy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_220'>\n\t\t\t<li class='gchoice gchoice_6_220_0'>\n\t\t\t\t<input name='input_220' type='radio' value='Yes'  id='choice_6_220_0'    \/>\n\t\t\t\t<label for='choice_6_220_0' id='label_6_220_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_220_1'>\n\t\t\t\t<input name='input_220' type='radio' value='No'  id='choice_6_220_1'    \/>\n\t\t\t\t<label for='choice_6_220_1' id='label_6_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you suffer from dry mouth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_221'>\n\t\t\t<li class='gchoice gchoice_6_221_0'>\n\t\t\t\t<input name='input_221' type='radio' value='Yes'  id='choice_6_221_0'    \/>\n\t\t\t\t<label for='choice_6_221_0' id='label_6_221_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_221_1'>\n\t\t\t\t<input name='input_221' type='radio' value='No'  id='choice_6_221_1'    \/>\n\t\t\t\t<label for='choice_6_221_1' id='label_6_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_222\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sexually transmitted or blood-borne infections (STBBI)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_222'>\n\t\t\t<li class='gchoice gchoice_6_222_0'>\n\t\t\t\t<input name='input_222' type='radio' value='Yes'  id='choice_6_222_0'    \/>\n\t\t\t\t<label for='choice_6_222_0' id='label_6_222_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_222_1'>\n\t\t\t\t<input name='input_222' type='radio' value='No'  id='choice_6_222_1'    \/>\n\t\t\t\t<label for='choice_6_222_1' id='label_6_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_223\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_223'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_6_223' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_224\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Skin diseases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_224'>\n\t\t\t<li class='gchoice gchoice_6_224_0'>\n\t\t\t\t<input name='input_224' type='radio' value='Yes'  id='choice_6_224_0'    \/>\n\t\t\t\t<label for='choice_6_224_0' id='label_6_224_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_224_1'>\n\t\t\t\t<input name='input_224' type='radio' value='No'  id='choice_6_224_1'    \/>\n\t\t\t\t<label for='choice_6_224_1' id='label_6_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Eye disorders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_225'>\n\t\t\t<li class='gchoice gchoice_6_225_0'>\n\t\t\t\t<input name='input_225' type='radio' value='Yes'  id='choice_6_225_0'    \/>\n\t\t\t\t<label for='choice_6_225_0' id='label_6_225_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_225_1'>\n\t\t\t\t<input name='input_225' type='radio' value='No'  id='choice_6_225_1'    \/>\n\t\t\t\t<label for='choice_6_225_1' id='label_6_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_226\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Earaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_226'>\n\t\t\t<li class='gchoice gchoice_6_226_0'>\n\t\t\t\t<input name='input_226' type='radio' value='Yes'  id='choice_6_226_0'    \/>\n\t\t\t\t<label for='choice_6_226_0' id='label_6_226_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_226_1'>\n\t\t\t\t<input name='input_226' type='radio' value='No'  id='choice_6_226_1'    \/>\n\t\t\t\t<label for='choice_6_226_1' id='label_6_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_227\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Arthritis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_227'>\n\t\t\t<li class='gchoice gchoice_6_227_0'>\n\t\t\t\t<input name='input_227' type='radio' value='Yes'  id='choice_6_227_0'    \/>\n\t\t\t\t<label for='choice_6_227_0' id='label_6_227_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_227_1'>\n\t\t\t\t<input name='input_227' type='radio' value='No'  id='choice_6_227_1'    \/>\n\t\t\t\t<label for='choice_6_227_1' id='label_6_227_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chronic pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_231'>\n\t\t\t<li class='gchoice gchoice_6_231_0'>\n\t\t\t\t<input name='input_231' type='radio' value='Yes'  id='choice_6_231_0'    \/>\n\t\t\t\t<label for='choice_6_231_0' id='label_6_231_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_231_1'>\n\t\t\t\t<input name='input_231' type='radio' value='No'  id='choice_6_231_1'    \/>\n\t\t\t\t<label for='choice_6_231_1' id='label_6_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_232\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Epilepsy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_232'>\n\t\t\t<li class='gchoice gchoice_6_232_0'>\n\t\t\t\t<input name='input_232' type='radio' value='Yes'  id='choice_6_232_0'    \/>\n\t\t\t\t<label for='choice_6_232_0' id='label_6_232_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_232_1'>\n\t\t\t\t<input name='input_232' type='radio' value='No'  id='choice_6_232_1'    \/>\n\t\t\t\t<label for='choice_6_232_1' id='label_6_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_235\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent colds or sinusitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_235'>\n\t\t\t<li class='gchoice gchoice_6_235_0'>\n\t\t\t\t<input name='input_235' type='radio' value='Yes'  id='choice_6_235_0'    \/>\n\t\t\t\t<label for='choice_6_235_0' id='label_6_235_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_235_1'>\n\t\t\t\t<input name='input_235' type='radio' value='No'  id='choice_6_235_1'    \/>\n\t\t\t\t<label for='choice_6_235_1' id='label_6_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_237\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_237'>\n\t\t\t<li class='gchoice gchoice_6_237_0'>\n\t\t\t\t<input name='input_237' type='radio' value='Yes'  id='choice_6_237_0'    \/>\n\t\t\t\t<label for='choice_6_237_0' id='label_6_237_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_237_1'>\n\t\t\t\t<input name='input_237' type='radio' value='No'  id='choice_6_237_1'    \/>\n\t\t\t\t<label for='choice_6_237_1' id='label_6_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hay fever \/ seasonal allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_238'>\n\t\t\t<li class='gchoice gchoice_6_238_0'>\n\t\t\t\t<input name='input_238' type='radio' value='Yes'  id='choice_6_238_0'    \/>\n\t\t\t\t<label for='choice_6_238_0' id='label_6_238_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_238_1'>\n\t\t\t\t<input name='input_238' type='radio' value='No'  id='choice_6_238_1'    \/>\n\t\t\t\t<label for='choice_6_238_1' id='label_6_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tuberculosis or lung disorders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_236'>\n\t\t\t<li class='gchoice gchoice_6_236_0'>\n\t\t\t\t<input name='input_236' type='radio' value='Yes'  id='choice_6_236_0'    \/>\n\t\t\t\t<label for='choice_6_236_0' id='label_6_236_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_236_1'>\n\t\t\t\t<input name='input_236' type='radio' value='No'  id='choice_6_236_1'    \/>\n\t\t\t\t<label for='choice_6_236_1' id='label_6_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_233\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Nervous system disorders or diseases<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_233'>\n\t\t\t<li class='gchoice gchoice_6_233_0'>\n\t\t\t\t<input name='input_233' type='radio' value='Yes'  id='choice_6_233_0'    \/>\n\t\t\t\t<label for='choice_6_233_0' id='label_6_233_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_233_1'>\n\t\t\t\t<input name='input_233' type='radio' value='No'  id='choice_6_233_1'    \/>\n\t\t\t\t<label for='choice_6_233_1' id='label_6_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Mental disorders or illnesses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_234'>\n\t\t\t<li class='gchoice gchoice_6_234_0'>\n\t\t\t\t<input name='input_234' type='radio' value='Yes'  id='choice_6_234_0'    \/>\n\t\t\t\t<label for='choice_6_234_0' id='label_6_234_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_234_1'>\n\t\t\t\t<input name='input_234' type='radio' value='No'  id='choice_6_234_1'    \/>\n\t\t\t\t<label for='choice_6_234_1' id='label_6_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_228\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Osteoporosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_228'>\n\t\t\t<li class='gchoice gchoice_6_228_0'>\n\t\t\t\t<input name='input_228' type='radio' value='Yes'  id='choice_6_228_0'    \/>\n\t\t\t\t<label for='choice_6_228_0' id='label_6_228_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_228_1'>\n\t\t\t\t<input name='input_228' type='radio' value='No'  id='choice_6_228_1'    \/>\n\t\t\t\t<label for='choice_6_228_1' id='label_6_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Annual or monthly injection<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_230'>\n\t\t\t<li class='gchoice gchoice_6_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='Yes'  id='choice_6_230_0'    \/>\n\t\t\t\t<label for='choice_6_230_0' id='label_6_230_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_6_230_1'    \/>\n\t\t\t\t<label for='choice_6_230_1' id='label_6_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_229\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Prevention \/ treatment (e.g.: tablets)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_229'>\n\t\t\t<li class='gchoice gchoice_6_229_0'>\n\t\t\t\t<input name='input_229' type='radio' value='Yes'  id='choice_6_229_0'    \/>\n\t\t\t\t<label for='choice_6_229_0' id='label_6_229_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_229_1'>\n\t\t\t\t<input name='input_229' type='radio' value='No'  id='choice_6_229_1'    \/>\n\t\t\t\t<label for='choice_6_229_1' id='label_6_229_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_240\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Allergy or manifestation with products containing:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_240'><li class='gchoice gchoice_6_240_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.1' type='checkbox'  value='Latex'  id='choice_6_240_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_1' id='label_6_240_1' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.2' type='checkbox'  value='Penicillin'  id='choice_6_240_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_2' id='label_6_240_2' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.3' type='checkbox'  value='Other antibiotics'  id='choice_6_240_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_3' id='label_6_240_3' class='gform-field-label gform-field-label--type-inline'>Other antibiotics<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.4' type='checkbox'  value='Codeine'  id='choice_6_240_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_4' id='label_6_240_4' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.5' type='checkbox'  value='Aspirin'  id='choice_6_240_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_5' id='label_6_240_5' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.6' type='checkbox'  value='Sulfonamides'  id='choice_6_240_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_6' id='label_6_240_6' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.7' type='checkbox'  value='Anesthetic'  id='choice_6_240_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_7' id='label_6_240_7' class='gform-field-label gform-field-label--type-inline'>Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.8' type='checkbox'  value='Food'  id='choice_6_240_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_8' id='label_6_240_8' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.9' type='checkbox'  value='Iodine-containing products'  id='choice_6_240_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_9' id='label_6_240_9' class='gform-field-label gform-field-label--type-inline'>Iodine-containing products<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_240_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.11' type='checkbox'  value='Other'  id='choice_6_240_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_240_11' id='label_6_240_11' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_241\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_241'>Specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_6_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_120\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gf_left field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'>Other medical conditions that should be mentioned<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_6_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_242\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#000000;color:#ffffff;font-weight:bold;font-size:16px;\">Other aspects<\/div><\/li><li id=\"field_6_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you snore?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_243'>\n\t\t\t<li class='gchoice gchoice_6_243_0'>\n\t\t\t\t<input name='input_243' type='radio' value='Yes'  id='choice_6_243_0'    \/>\n\t\t\t\t<label for='choice_6_243_0' id='label_6_243_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_243_1'>\n\t\t\t\t<input name='input_243' type='radio' value='No'  id='choice_6_243_1'    \/>\n\t\t\t\t<label for='choice_6_243_1' id='label_6_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you suffer from sleep apnea?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_244'>\n\t\t\t<li class='gchoice gchoice_6_244_0'>\n\t\t\t\t<input name='input_244' type='radio' value='Yes'  id='choice_6_244_0'    \/>\n\t\t\t\t<label for='choice_6_244_0' id='label_6_244_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_244_1'>\n\t\t\t\t<input name='input_244' type='radio' value='No'  id='choice_6_244_1'    \/>\n\t\t\t\t<label for='choice_6_244_1' id='label_6_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_245'>\n\t\t\t<li class='gchoice gchoice_6_245_0'>\n\t\t\t\t<input name='input_245' type='radio' value='Yes'  id='choice_6_245_0'    \/>\n\t\t\t\t<label for='choice_6_245_0' id='label_6_245_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_245_1'>\n\t\t\t\t<input name='input_245' type='radio' value='No'  id='choice_6_245_1'    \/>\n\t\t\t\t<label for='choice_6_245_1' id='label_6_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_245_2'>\n\t\t\t\t<input name='input_245' type='radio' value='Ex-smoker'  id='choice_6_245_2'    \/>\n\t\t\t\t<label for='choice_6_245_2' id='label_6_245_2' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_246\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_246'>How many cigarettes do you smoke per day?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_246' id='input_6_246' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you drink alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_247'>\n\t\t\t<li class='gchoice gchoice_6_247_0'>\n\t\t\t\t<input name='input_247' type='radio' value='Yes'  id='choice_6_247_0'    \/>\n\t\t\t\t<label for='choice_6_247_0' id='label_6_247_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_247_1'>\n\t\t\t\t<input name='input_247' type='radio' value='No'  id='choice_6_247_1'    \/>\n\t\t\t\t<label for='choice_6_247_1' id='label_6_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_250\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_250'>The number of drinks - per day, week or month:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_250' id='input_6_250' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take drugs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_252'>\n\t\t\t<li class='gchoice gchoice_6_252_0'>\n\t\t\t\t<input name='input_252' type='radio' value='Yes'  id='choice_6_252_0'    \/>\n\t\t\t\t<label for='choice_6_252_0' id='label_6_252_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_252_1'>\n\t\t\t\t<input name='input_252' type='radio' value='No'  id='choice_6_252_1'    \/>\n\t\t\t\t<label for='choice_6_252_1' id='label_6_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_253\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take methadone?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_253'>\n\t\t\t<li class='gchoice gchoice_6_253_0'>\n\t\t\t\t<input name='input_253' type='radio' value='Yes'  id='choice_6_253_0'    \/>\n\t\t\t\t<label for='choice_6_253_0' id='label_6_253_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_253_1'>\n\t\t\t\t<input name='input_253' type='radio' value='No'  id='choice_6_253_1'    \/>\n\t\t\t\t<label for='choice_6_253_1' id='label_6_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#000000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div>\n<\/li><li id=\"field_6_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Dental and medical history acceptance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_6_88_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_88_1' >I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.<\/label><input type='hidden' name='input_88.2' value='I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.' class='gform_hidden' \/><input 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