{"id":3157,"date":"2022-05-03T18:05:25","date_gmt":"2022-05-03T18:05:25","guid":{"rendered":"https:\/\/cotegilbert.com\/nouveau\/medical-form-for-new-patients\/"},"modified":"2022-05-05T18:32:09","modified_gmt":"2022-05-05T18:32:09","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/cotegilbert.com\/en\/medical-questionnaire\/","title":{"rendered":"Medical Questionnaire"},"content":{"rendered":"<p>[vc_row full_width=&#8221;stretch_row_content_no_spaces&#8221;][vc_column][vc_single_image image=&#8221;2929&#8243; img_size=&#8221;full&#8221;][\/vc_column][\/vc_row][vc_row hide_bg_image_on_tablet=&#8221;&#8221; hide_bg_image_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651768514961{margin-top: 40px !important;margin-bottom: 80px !important;}&#8221;][vc_column][vc_empty_space height=&#8221;10px&#8221; alter_height=&#8221;none&#8221; hide_on_desktop=&#8221;&#8221; hide_on_notebook=&#8221;&#8221; hide_on_tablet=&#8221;&#8221; hide_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651580449948{margin-top: -0.25rem !important;}&#8221;][vc_custom_heading text=&#8221;Medical Form for New Patients&#8221; font_container=&#8221;tag:h2|font_size:45px|text_align:left|color:%23797979|line_height:45px&#8221; use_theme_fonts=&#8221;yes&#8221;][vc_column_text]<span style=\"color: #f79c88;\"><strong>You are a new patient?<\/strong><\/span><\/p>\n<p>You must first complete a questionnaire collecting all details related to your health status prior to your first appointment. In order to accelerate the process, we invite you to fill-in the following questionnaire at home :[\/vc_column_text][vc_empty_space height=&#8221;30px&#8221; alter_height=&#8221;none&#8221; hide_on_desktop=&#8221;&#8221; hide_on_notebook=&#8221;&#8221; hide_on_tablet=&#8221;&#8221; hide_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651600970841{margin-top: -0.25rem !important;}&#8221;]<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_13' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_13'  action='\/en\/wp-json\/wp\/v2\/pages\/3157' data-formid='13' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_13_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_13_258'>X\/Twitter<\/label><div class='ginput_container'><input name='input_258' id='input_13_258' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_13_258'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_13_41\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#f3937d;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATIONS<\/div><\/li><li id=\"field_13_173\" class=\"gfield gfield--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_13_173'>* Veuillez porter attention<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_13_173' type='text' value='* OUI * ' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_11\" class=\"gfield gfield--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_13_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_13_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_8\" class=\"gfield gfield--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_13_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_13_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_175\" class=\"gfield gfield--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_13_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_13_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_35\" class=\"gfield gfield--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_13_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_13_35_2_container'><label for='input_13_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_13_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_13_35_1_container'><label for='input_13_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_13_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_13_35_3_container'><label for='input_13_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_13_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_13_13\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_13'>\n\t\t\t<li class='gchoice gchoice_13_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='M'  id='choice_13_13_0'    \/>\n\t\t\t\t<label for='choice_13_13_0' id='label_13_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_13_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='F'  id='choice_13_13_1'    \/>\n\t\t\t\t<label for='choice_13_13_1' id='label_13_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_13_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Other'  id='choice_13_13_2'    \/>\n\t\t\t\t<label for='choice_13_13_2' id='label_13_13_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_123\" class=\"gfield gfield--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_13_123'>Health Ins. No.<\/label><div class='gfield_description' id='gfield_description_13_123'>(To be completed for children aged 10 and under)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_13_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_13_123\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_254\" class=\"gfield gfield--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_13_254'>Expiration<\/label><div class='gfield_description' id='gfield_description_13_254'>(MM\/YYYY)<\/div><div class='ginput_container ginput_container_text'><input name='input_254' id='input_13_254' type='text' value='' class='medium'  aria-describedby=\"gfield_description_13_254\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_36\" class=\"gfield gfield--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_13_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_13_36' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_38\" class=\"gfield gfield--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_13_38'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_13_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_37\" class=\"gfield gfield--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_13_37'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_13_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_34\" class=\"gfield gfield--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_13_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_13_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_13_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_13_34_1' id='input_13_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_13_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_13_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_13_34_3' id='input_13_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_13_34_4_container' >\n                                        <select name='input_34.4' id='input_13_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_13_34_4' id='input_13_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_13_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_13_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_13_34_5' id='input_13_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_13_34_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_13_126\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_126'>\n\t\t\t<li class='gchoice gchoice_13_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_13_126_0'    \/>\n\t\t\t\t<label for='choice_13_126_0' id='label_13_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_13_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_13_126_1'    \/>\n\t\t\t\t<label for='choice_13_126_1' id='label_13_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_46\" class=\"gfield gfield--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_13_46'>Father&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_13_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_127\" class=\"gfield gfield--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_13_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_13_127' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_128\" class=\"gfield gfield--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_13_128'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_13_128' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_129\" class=\"gfield gfield--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_13_129'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_13_129' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_130\" class=\"gfield gfield--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_13_130'>Mother&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_13_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_133\" class=\"gfield gfield--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_13_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_13_133' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_132\" class=\"gfield gfield--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_13_132'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_13_132' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_131\" class=\"gfield gfield--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_13_131'>Work Tel.<\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_13_131' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_134\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_134'>\n\t\t\t<li class='gchoice gchoice_13_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Father'  id='choice_13_134_0'    \/>\n\t\t\t\t<label for='choice_13_134_0' id='label_13_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_13_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Mother'  id='choice_13_134_1'    \/>\n\t\t\t\t<label for='choice_13_134_1' id='label_13_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_13_134_2'>\n\t\t\t\t<input name='input_134' type='radio' value='Other'  id='choice_13_134_2'    \/>\n\t\t\t\t<label for='choice_13_134_2' id='label_13_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_47\" class=\"gfield gfield--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_13_47'>Specify Other<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_13_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_40\" class=\"gfield gfield--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_13_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_13_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_13_179\" class=\"gfield gfield--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_13_179'>\n                            \n                            <span id='input_13_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_13_179_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_13_179_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            <span id='input_13_179_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.4' id='input_13_179_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_13_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_13_180\" class=\"gfield gfield--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_13_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_13_180' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_181\" class=\"gfield gfield--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_13_181'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_181' id='input_13_181' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_42\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#f3937d;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL INFORMATION<\/div><\/li><li id=\"field_13_139\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_15'>\n\t\t\t<li class='gchoice gchoice_13_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='0-6 month'  id='choice_13_15_0'    \/>\n\t\t\t\t<label for='choice_13_15_0' id='label_13_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_13_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='6-12 month'  id='choice_13_15_1'    \/>\n\t\t\t\t<label for='choice_13_15_1' id='label_13_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_13_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='+12 month'  id='choice_13_15_2'    \/>\n\t\t\t\t<label for='choice_13_15_2' id='label_13_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_13_182\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_142'>\n\t\t\t<li class='gchoice gchoice_13_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_13_142_0'    \/>\n\t\t\t\t<label for='choice_13_142_0' id='label_13_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_13_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_13_142_1'    \/>\n\t\t\t\t<label for='choice_13_142_1' id='label_13_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_143\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_143'>\n\t\t\t<li class='gchoice gchoice_13_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_13_143_0'    \/>\n\t\t\t\t<label for='choice_13_143_0' id='label_13_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_13_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_13_143_1'    \/>\n\t\t\t\t<label for='choice_13_143_1' id='label_13_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_145\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_145'>\n\t\t\t<li class='gchoice gchoice_13_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Not at all'  id='choice_13_145_0'    \/>\n\t\t\t\t<label for='choice_13_145_0' id='label_13_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_13_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='A little'  id='choice_13_145_1'    \/>\n\t\t\t\t<label for='choice_13_145_1' id='label_13_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_13_145_2'>\n\t\t\t\t<input name='input_145' type='radio' value='Very much'  id='choice_13_145_2'    \/>\n\t\t\t\t<label for='choice_13_145_2' id='label_13_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_13_136\" class=\"gfield gfield--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_13_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_13_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_183\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_183'>\n\t\t\t<li class='gchoice gchoice_13_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='Yes'  id='choice_13_183_0'    \/>\n\t\t\t\t<label for='choice_13_183_0' id='label_13_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_13_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_13_183_1'    \/>\n\t\t\t\t<label for='choice_13_183_1' id='label_13_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_184\" class=\"gfield gfield--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_13_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_13_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_185\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_185'>\n\t\t\t<li class='gchoice gchoice_13_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='Yes'  id='choice_13_185_0'    \/>\n\t\t\t\t<label for='choice_13_185_0' id='label_13_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_13_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_13_185_1'    \/>\n\t\t\t\t<label for='choice_13_185_1' id='label_13_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_186\" class=\"gfield gfield--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_13_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_13_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_256\" class=\"gfield gfield--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_13_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_13_256' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_255\" class=\"gfield gfield--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_13_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_13_255' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_187\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_187'>\n\t\t\t<li class='gchoice gchoice_13_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='Yes'  id='choice_13_187_0'    \/>\n\t\t\t\t<label for='choice_13_187_0' id='label_13_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_13_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_13_187_1'    \/>\n\t\t\t\t<label for='choice_13_187_1' id='label_13_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_188\" class=\"gfield gfield--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_13_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_13_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_189\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_189'>\n\t\t\t<li class='gchoice gchoice_13_189_0'>\n\t\t\t\t<input name='input_189' type='radio' value='Yes'  id='choice_13_189_0'    \/>\n\t\t\t\t<label for='choice_13_189_0' id='label_13_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_13_189_1'>\n\t\t\t\t<input name='input_189' type='radio' value='No'  id='choice_13_189_1'    \/>\n\t\t\t\t<label for='choice_13_189_1' id='label_13_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_190\" class=\"gfield gfield--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_13_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_13_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_191\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_191'>\n\t\t\t<li class='gchoice gchoice_13_191_0'>\n\t\t\t\t<input name='input_191' type='radio' value='Yes'  id='choice_13_191_0'    \/>\n\t\t\t\t<label for='choice_13_191_0' id='label_13_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_13_191_1'>\n\t\t\t\t<input name='input_191' type='radio' value='No'  id='choice_13_191_1'    \/>\n\t\t\t\t<label for='choice_13_191_1' id='label_13_191_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_192\" class=\"gfield gfield--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_13_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_13_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_193\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_193'>\n\t\t\t<li class='gchoice gchoice_13_193_0'>\n\t\t\t\t<input name='input_193' type='radio' value='Yes'  id='choice_13_193_0'    \/>\n\t\t\t\t<label for='choice_13_193_0' id='label_13_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_13_193_1'>\n\t\t\t\t<input name='input_193' type='radio' value='No'  id='choice_13_193_1'    \/>\n\t\t\t\t<label for='choice_13_193_1' id='label_13_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_194\" class=\"gfield gfield--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_13_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_13_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_195\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_195'>\n\t\t\t<li class='gchoice gchoice_13_195_0'>\n\t\t\t\t<input name='input_195' type='radio' value='Yes'  id='choice_13_195_0'    \/>\n\t\t\t\t<label for='choice_13_195_0' id='label_13_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_13_195_1'>\n\t\t\t\t<input name='input_195' type='radio' value='No'  id='choice_13_195_1'    \/>\n\t\t\t\t<label for='choice_13_195_1' id='label_13_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_196\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_196'>\n\t\t\t<li class='gchoice gchoice_13_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='Yes'  id='choice_13_196_0'    \/>\n\t\t\t\t<label for='choice_13_196_0' id='label_13_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_13_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='No'  id='choice_13_196_1'    \/>\n\t\t\t\t<label for='choice_13_196_1' id='label_13_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_197\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_197'>\n\t\t\t<li class='gchoice gchoice_13_197_0'>\n\t\t\t\t<input name='input_197' type='radio' value='Yes'  id='choice_13_197_0'    \/>\n\t\t\t\t<label for='choice_13_197_0' id='label_13_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_13_197_1'>\n\t\t\t\t<input name='input_197' type='radio' value='No'  id='choice_13_197_1'    \/>\n\t\t\t\t<label for='choice_13_197_1' id='label_13_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_198\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_198'>\n\t\t\t<li class='gchoice gchoice_13_198_0'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes birth control'  id='choice_13_198_0'    \/>\n\t\t\t\t<label for='choice_13_198_0' id='label_13_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_13_198_1'>\n\t\t\t\t<input name='input_198' type='radio' value='Yes hormones'  id='choice_13_198_1'    \/>\n\t\t\t\t<label for='choice_13_198_1' id='label_13_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_13_198_2'>\n\t\t\t\t<input name='input_198' type='radio' value='No'  id='choice_13_198_2'    \/>\n\t\t\t\t<label for='choice_13_198_2' id='label_13_198_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_199\" class=\"gfield gfield--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_13_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_13_199' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_13_138\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#f3937d;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR CURRENT CONDITION<\/div><\/li><li id=\"field_13_167\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#f3937d;font-weight:bold;font-size:16px;\">Blood disorders<\/div><\/li><li id=\"field_13_55\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_55'>\n\t\t\t<li class='gchoice gchoice_13_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Yes'  id='choice_13_55_0'    \/>\n\t\t\t\t<label for='choice_13_55_0' id='label_13_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_13_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_13_55_1'    \/>\n\t\t\t\t<label for='choice_13_55_1' id='label_13_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_201\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#f3937d;font-weight:bold;font-size:16px;\">Heart conditions<\/div><\/li><li id=\"field_13_54\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_54'>\n\t\t\t<li class='gchoice gchoice_13_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_13_54_0'    \/>\n\t\t\t\t<label for='choice_13_54_0' id='label_13_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_13_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_13_54_1'    \/>\n\t\t\t\t<label for='choice_13_54_1' id='label_13_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_202\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_202'>\n\t\t\t<li class='gchoice gchoice_13_202_0'>\n\t\t\t\t<input name='input_202' type='radio' value='Yes'  id='choice_13_202_0'    \/>\n\t\t\t\t<label for='choice_13_202_0' id='label_13_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_13_202_1'>\n\t\t\t\t<input name='input_202' type='radio' value='No'  id='choice_13_202_1'    \/>\n\t\t\t\t<label for='choice_13_202_1' id='label_13_202_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_203\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_203'>\n\t\t\t<li class='gchoice gchoice_13_203_0'>\n\t\t\t\t<input name='input_203' type='radio' value='Yes'  id='choice_13_203_0'    \/>\n\t\t\t\t<label for='choice_13_203_0' id='label_13_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_13_203_1'>\n\t\t\t\t<input name='input_203' type='radio' value='No'  id='choice_13_203_1'    \/>\n\t\t\t\t<label for='choice_13_203_1' id='label_13_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_204\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#f3937d;font-weight:bold;font-size:16px;\">Other<\/div><\/li><li id=\"field_13_57\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_57'>\n\t\t\t<li class='gchoice gchoice_13_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - Low'  id='choice_13_57_0'    \/>\n\t\t\t\t<label for='choice_13_57_0' id='label_13_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_13_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - High'  id='choice_13_57_1'    \/>\n\t\t\t\t<label for='choice_13_57_1' id='label_13_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_13_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_13_57_2'    \/>\n\t\t\t\t<label for='choice_13_57_2' id='label_13_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_205\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_205'>\n\t\t\t<li class='gchoice gchoice_13_205_0'>\n\t\t\t\t<input name='input_205' type='radio' value='Yes'  id='choice_13_205_0'    \/>\n\t\t\t\t<label for='choice_13_205_0' id='label_13_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_13_205_1'>\n\t\t\t\t<input name='input_205' type='radio' value='No'  id='choice_13_205_1'    \/>\n\t\t\t\t<label for='choice_13_205_1' id='label_13_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_206\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_206'>\n\t\t\t<li class='gchoice gchoice_13_206_0'>\n\t\t\t\t<input name='input_206' type='radio' value='Yes'  id='choice_13_206_0'    \/>\n\t\t\t\t<label for='choice_13_206_0' id='label_13_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_13_206_1'>\n\t\t\t\t<input name='input_206' type='radio' value='No'  id='choice_13_206_1'    \/>\n\t\t\t\t<label for='choice_13_206_1' id='label_13_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_207\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_207'>\n\t\t\t<li class='gchoice gchoice_13_207_0'>\n\t\t\t\t<input name='input_207' type='radio' value='Yes'  id='choice_13_207_0'    \/>\n\t\t\t\t<label for='choice_13_207_0' id='label_13_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_13_207_1'>\n\t\t\t\t<input name='input_207' type='radio' value='No'  id='choice_13_207_1'    \/>\n\t\t\t\t<label for='choice_13_207_1' id='label_13_207_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_208\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_208'>\n\t\t\t<li class='gchoice gchoice_13_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='Yes'  id='choice_13_208_0'    \/>\n\t\t\t\t<label for='choice_13_208_0' id='label_13_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_13_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='No'  id='choice_13_208_1'    \/>\n\t\t\t\t<label for='choice_13_208_1' id='label_13_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_209\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_209'>\n\t\t\t<li class='gchoice gchoice_13_209_0'>\n\t\t\t\t<input name='input_209' type='radio' value='Yes'  id='choice_13_209_0'    \/>\n\t\t\t\t<label for='choice_13_209_0' id='label_13_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_13_209_1'>\n\t\t\t\t<input name='input_209' type='radio' value='No'  id='choice_13_209_1'    \/>\n\t\t\t\t<label for='choice_13_209_1' id='label_13_209_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_210\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_211\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_211'>\n\t\t\t<li class='gchoice gchoice_13_211_0'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Ulcer'  id='choice_13_211_0'    \/>\n\t\t\t\t<label for='choice_13_211_0' id='label_13_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_13_211_1'>\n\t\t\t\t<input name='input_211' type='radio' value='Yes, Reflux'  id='choice_13_211_1'    \/>\n\t\t\t\t<label for='choice_13_211_1' id='label_13_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_13_211_2'>\n\t\t\t\t<input name='input_211' type='radio' value='No'  id='choice_13_211_2'    \/>\n\t\t\t\t<label for='choice_13_211_2' id='label_13_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_212\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_212'>\n\t\t\t<li class='gchoice gchoice_13_212_0'>\n\t\t\t\t<input name='input_212' type='radio' value='Yes'  id='choice_13_212_0'    \/>\n\t\t\t\t<label for='choice_13_212_0' id='label_13_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_13_212_1'>\n\t\t\t\t<input name='input_212' type='radio' value='No'  id='choice_13_212_1'    \/>\n\t\t\t\t<label for='choice_13_212_1' id='label_13_212_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_213\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_213'>\n\t\t\t<li class='gchoice gchoice_13_213_0'>\n\t\t\t\t<input name='input_213' type='radio' value='Yes'  id='choice_13_213_0'    \/>\n\t\t\t\t<label for='choice_13_213_0' id='label_13_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_13_213_1'>\n\t\t\t\t<input name='input_213' type='radio' value='No'  id='choice_13_213_1'    \/>\n\t\t\t\t<label for='choice_13_213_1' id='label_13_213_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_214\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_214'>\n\t\t\t<li class='gchoice gchoice_13_214_0'>\n\t\t\t\t<input name='input_214' type='radio' value='Yes'  id='choice_13_214_0'    \/>\n\t\t\t\t<label for='choice_13_214_0' id='label_13_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_13_214_1'>\n\t\t\t\t<input name='input_214' type='radio' value='No'  id='choice_13_214_1'    \/>\n\t\t\t\t<label for='choice_13_214_1' id='label_13_214_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_217\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><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_13_217'>\n\t\t\t<li class='gchoice gchoice_13_217_0'>\n\t\t\t\t<input name='input_217' type='radio' value='Yes'  id='choice_13_217_0'    \/>\n\t\t\t\t<label for='choice_13_217_0' id='label_13_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_13_217_1'>\n\t\t\t\t<input name='input_217' type='radio' value='No'  id='choice_13_217_1'    \/>\n\t\t\t\t<label for='choice_13_217_1' id='label_13_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_218\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_218' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_219\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_219'>\n\t\t\t<li class='gchoice gchoice_13_219_0'>\n\t\t\t\t<input name='input_219' type='radio' value='Yes'  id='choice_13_219_0'    \/>\n\t\t\t\t<label for='choice_13_219_0' id='label_13_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_13_219_1'>\n\t\t\t\t<input name='input_219' type='radio' value='No'  id='choice_13_219_1'    \/>\n\t\t\t\t<label for='choice_13_219_1' id='label_13_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_220\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_220'>\n\t\t\t<li class='gchoice gchoice_13_220_0'>\n\t\t\t\t<input name='input_220' type='radio' value='Yes'  id='choice_13_220_0'    \/>\n\t\t\t\t<label for='choice_13_220_0' id='label_13_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_13_220_1'>\n\t\t\t\t<input name='input_220' type='radio' value='No'  id='choice_13_220_1'    \/>\n\t\t\t\t<label for='choice_13_220_1' id='label_13_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_221\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_221'>\n\t\t\t<li class='gchoice gchoice_13_221_0'>\n\t\t\t\t<input name='input_221' type='radio' value='Yes'  id='choice_13_221_0'    \/>\n\t\t\t\t<label for='choice_13_221_0' id='label_13_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_13_221_1'>\n\t\t\t\t<input name='input_221' type='radio' value='No'  id='choice_13_221_1'    \/>\n\t\t\t\t<label for='choice_13_221_1' id='label_13_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_222\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_222'>\n\t\t\t<li class='gchoice gchoice_13_222_0'>\n\t\t\t\t<input name='input_222' type='radio' value='Yes'  id='choice_13_222_0'    \/>\n\t\t\t\t<label for='choice_13_222_0' id='label_13_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_13_222_1'>\n\t\t\t\t<input name='input_222' type='radio' value='No'  id='choice_13_222_1'    \/>\n\t\t\t\t<label for='choice_13_222_1' id='label_13_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_223\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_223' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_224\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_224'>\n\t\t\t<li class='gchoice gchoice_13_224_0'>\n\t\t\t\t<input name='input_224' type='radio' value='Yes'  id='choice_13_224_0'    \/>\n\t\t\t\t<label for='choice_13_224_0' id='label_13_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_13_224_1'>\n\t\t\t\t<input name='input_224' type='radio' value='No'  id='choice_13_224_1'    \/>\n\t\t\t\t<label for='choice_13_224_1' id='label_13_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_225\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_225'>\n\t\t\t<li class='gchoice gchoice_13_225_0'>\n\t\t\t\t<input name='input_225' type='radio' value='Yes'  id='choice_13_225_0'    \/>\n\t\t\t\t<label for='choice_13_225_0' id='label_13_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_13_225_1'>\n\t\t\t\t<input name='input_225' type='radio' value='No'  id='choice_13_225_1'    \/>\n\t\t\t\t<label for='choice_13_225_1' id='label_13_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_226\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_226'>\n\t\t\t<li class='gchoice gchoice_13_226_0'>\n\t\t\t\t<input name='input_226' type='radio' value='Yes'  id='choice_13_226_0'    \/>\n\t\t\t\t<label for='choice_13_226_0' id='label_13_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_13_226_1'>\n\t\t\t\t<input name='input_226' type='radio' value='No'  id='choice_13_226_1'    \/>\n\t\t\t\t<label for='choice_13_226_1' id='label_13_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_227\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_227'>\n\t\t\t<li class='gchoice gchoice_13_227_0'>\n\t\t\t\t<input name='input_227' type='radio' value='Yes'  id='choice_13_227_0'    \/>\n\t\t\t\t<label for='choice_13_227_0' id='label_13_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_13_227_1'>\n\t\t\t\t<input name='input_227' type='radio' value='No'  id='choice_13_227_1'    \/>\n\t\t\t\t<label for='choice_13_227_1' id='label_13_227_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_231\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_231'>\n\t\t\t<li class='gchoice gchoice_13_231_0'>\n\t\t\t\t<input name='input_231' type='radio' value='Yes'  id='choice_13_231_0'    \/>\n\t\t\t\t<label for='choice_13_231_0' id='label_13_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_13_231_1'>\n\t\t\t\t<input name='input_231' type='radio' value='No'  id='choice_13_231_1'    \/>\n\t\t\t\t<label for='choice_13_231_1' id='label_13_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_232\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_232'>\n\t\t\t<li class='gchoice gchoice_13_232_0'>\n\t\t\t\t<input name='input_232' type='radio' value='Yes'  id='choice_13_232_0'    \/>\n\t\t\t\t<label for='choice_13_232_0' id='label_13_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_13_232_1'>\n\t\t\t\t<input name='input_232' type='radio' value='No'  id='choice_13_232_1'    \/>\n\t\t\t\t<label for='choice_13_232_1' id='label_13_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_235\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_235'>\n\t\t\t<li class='gchoice gchoice_13_235_0'>\n\t\t\t\t<input name='input_235' type='radio' value='Yes'  id='choice_13_235_0'    \/>\n\t\t\t\t<label for='choice_13_235_0' id='label_13_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_13_235_1'>\n\t\t\t\t<input name='input_235' type='radio' value='No'  id='choice_13_235_1'    \/>\n\t\t\t\t<label for='choice_13_235_1' id='label_13_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_237\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_237'>\n\t\t\t<li class='gchoice gchoice_13_237_0'>\n\t\t\t\t<input name='input_237' type='radio' value='Yes'  id='choice_13_237_0'    \/>\n\t\t\t\t<label for='choice_13_237_0' id='label_13_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_13_237_1'>\n\t\t\t\t<input name='input_237' type='radio' value='No'  id='choice_13_237_1'    \/>\n\t\t\t\t<label for='choice_13_237_1' id='label_13_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_238\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_238'>\n\t\t\t<li class='gchoice gchoice_13_238_0'>\n\t\t\t\t<input name='input_238' type='radio' value='Yes'  id='choice_13_238_0'    \/>\n\t\t\t\t<label for='choice_13_238_0' id='label_13_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_13_238_1'>\n\t\t\t\t<input name='input_238' type='radio' value='No'  id='choice_13_238_1'    \/>\n\t\t\t\t<label for='choice_13_238_1' id='label_13_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_236\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_236'>\n\t\t\t<li class='gchoice gchoice_13_236_0'>\n\t\t\t\t<input name='input_236' type='radio' value='Yes'  id='choice_13_236_0'    \/>\n\t\t\t\t<label for='choice_13_236_0' id='label_13_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_13_236_1'>\n\t\t\t\t<input name='input_236' type='radio' value='No'  id='choice_13_236_1'    \/>\n\t\t\t\t<label for='choice_13_236_1' id='label_13_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_233\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_233'>\n\t\t\t<li class='gchoice gchoice_13_233_0'>\n\t\t\t\t<input name='input_233' type='radio' value='Yes'  id='choice_13_233_0'    \/>\n\t\t\t\t<label for='choice_13_233_0' id='label_13_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_13_233_1'>\n\t\t\t\t<input name='input_233' type='radio' value='No'  id='choice_13_233_1'    \/>\n\t\t\t\t<label for='choice_13_233_1' id='label_13_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_234\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_234'>\n\t\t\t<li class='gchoice gchoice_13_234_0'>\n\t\t\t\t<input name='input_234' type='radio' value='Yes'  id='choice_13_234_0'    \/>\n\t\t\t\t<label for='choice_13_234_0' id='label_13_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_13_234_1'>\n\t\t\t\t<input name='input_234' type='radio' value='No'  id='choice_13_234_1'    \/>\n\t\t\t\t<label for='choice_13_234_1' id='label_13_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_228\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><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_13_228'>\n\t\t\t<li class='gchoice gchoice_13_228_0'>\n\t\t\t\t<input name='input_228' type='radio' value='Yes'  id='choice_13_228_0'    \/>\n\t\t\t\t<label for='choice_13_228_0' id='label_13_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_13_228_1'>\n\t\t\t\t<input name='input_228' type='radio' value='No'  id='choice_13_228_1'    \/>\n\t\t\t\t<label for='choice_13_228_1' id='label_13_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_230\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_230'>\n\t\t\t<li class='gchoice gchoice_13_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='Yes'  id='choice_13_230_0'    \/>\n\t\t\t\t<label for='choice_13_230_0' id='label_13_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_13_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_13_230_1'    \/>\n\t\t\t\t<label for='choice_13_230_1' id='label_13_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_229\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_229'>\n\t\t\t<li class='gchoice gchoice_13_229_0'>\n\t\t\t\t<input name='input_229' type='radio' value='Yes'  id='choice_13_229_0'    \/>\n\t\t\t\t<label for='choice_13_229_0' id='label_13_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_13_229_1'>\n\t\t\t\t<input name='input_229' type='radio' value='No'  id='choice_13_229_1'    \/>\n\t\t\t\t<label for='choice_13_229_1' id='label_13_229_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_240\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_240'><li class='gchoice gchoice_13_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_13_240_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_1' id='label_13_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_13_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_13_240_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_2' id='label_13_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_13_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_13_240_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_3' id='label_13_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_13_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_13_240_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_4' id='label_13_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_13_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_13_240_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_5' id='label_13_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_13_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_13_240_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_6' id='label_13_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_13_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_13_240_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_7' id='label_13_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_13_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_13_240_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_8' id='label_13_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_13_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_13_240_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_9' id='label_13_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_13_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_13_240_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_240_11' id='label_13_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_13_241\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_120\" class=\"gfield gfield--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_13_120'>Other medical conditions that should be mentioned<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_13_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_13_242\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#ffffff;color:#f3937d;font-weight:bold;font-size:16px;\">Other aspects<\/div><\/li><li id=\"field_13_243\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_243'>\n\t\t\t<li class='gchoice gchoice_13_243_0'>\n\t\t\t\t<input name='input_243' type='radio' value='Yes'  id='choice_13_243_0'    \/>\n\t\t\t\t<label for='choice_13_243_0' id='label_13_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_13_243_1'>\n\t\t\t\t<input name='input_243' type='radio' value='No'  id='choice_13_243_1'    \/>\n\t\t\t\t<label for='choice_13_243_1' id='label_13_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_244\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_244'>\n\t\t\t<li class='gchoice gchoice_13_244_0'>\n\t\t\t\t<input name='input_244' type='radio' value='Yes'  id='choice_13_244_0'    \/>\n\t\t\t\t<label for='choice_13_244_0' id='label_13_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_13_244_1'>\n\t\t\t\t<input name='input_244' type='radio' value='No'  id='choice_13_244_1'    \/>\n\t\t\t\t<label for='choice_13_244_1' id='label_13_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_245\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_245'>\n\t\t\t<li class='gchoice gchoice_13_245_0'>\n\t\t\t\t<input name='input_245' type='radio' value='Yes'  id='choice_13_245_0'    \/>\n\t\t\t\t<label for='choice_13_245_0' id='label_13_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_13_245_1'>\n\t\t\t\t<input name='input_245' type='radio' value='No'  id='choice_13_245_1'    \/>\n\t\t\t\t<label for='choice_13_245_1' id='label_13_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_13_245_2'>\n\t\t\t\t<input name='input_245' type='radio' value='Ex-smoker'  id='choice_13_245_2'    \/>\n\t\t\t\t<label for='choice_13_245_2' id='label_13_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_13_246\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_246' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_247\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_247'>\n\t\t\t<li class='gchoice gchoice_13_247_0'>\n\t\t\t\t<input name='input_247' type='radio' value='Yes'  id='choice_13_247_0'    \/>\n\t\t\t\t<label for='choice_13_247_0' id='label_13_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_13_247_1'>\n\t\t\t\t<input name='input_247' type='radio' value='No'  id='choice_13_247_1'    \/>\n\t\t\t\t<label for='choice_13_247_1' id='label_13_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_250\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_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_13_250' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_252\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_252'>\n\t\t\t<li class='gchoice gchoice_13_252_0'>\n\t\t\t\t<input name='input_252' type='radio' value='Yes'  id='choice_13_252_0'    \/>\n\t\t\t\t<label for='choice_13_252_0' id='label_13_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_13_252_1'>\n\t\t\t\t<input name='input_252' type='radio' value='No'  id='choice_13_252_1'    \/>\n\t\t\t\t<label for='choice_13_252_1' id='label_13_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_253\" class=\"gfield gfield--type-radio gfield--type-choice 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_13_253'>\n\t\t\t<li class='gchoice gchoice_13_253_0'>\n\t\t\t\t<input name='input_253' type='radio' value='Yes'  id='choice_13_253_0'    \/>\n\t\t\t\t<label for='choice_13_253_0' id='label_13_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_13_253_1'>\n\t\t\t\t<input name='input_253' type='radio' value='No'  id='choice_13_253_1'    \/>\n\t\t\t\t<label for='choice_13_253_1' id='label_13_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_13_91\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#f3937d;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div>\n<br><br><strong>Please consult the following documents before your acceptance and signature:<\/strong><br><br>\n\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGConsentementpatientmoins14ans-eng.pdf\" target=\"_blank\"><strong>Consentement - Patient 14 ans et moins<\/strong><\/a><br>\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGConsentementpatientplus14ans-eng.pdf\" target=\"_blank\"><strong>Consentement - Patient 14 ans et plus<\/strong><\/a><br>\n<a href=\"https:\/\/cotegilbert.com\/wp-content\/uploads\/2023\/09\/SDCGPolitiqudeconfidentialite-eng.pdf\" target=\"_blank\"><strong>Politique de confidentialit\u00e9<\/strong><\/a><br><\/li><li id=\"field_13_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><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_13_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_13_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 type='hidden' name='input_88.3' value='3' class='gform_hidden' \/><\/div><\/li><li id=\"field_13_257\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of Collection, use, and disclosure of personal information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_257.1' id='input_13_257_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_257_1' >I hereby give my consent to the collection, use and disclosure of my personal information by Soins Dentaire C\u00f4t\u00e9 Gilbert for the purpose of providing dental services.<\/label><input type='hidden' name='input_257.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by Soins Dentaire C\u00f4t\u00e9 Gilbert for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_257.3' value='3' class='gform_hidden' \/><\/div><\/li><li id=\"field_13_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_2'>Signature of patient or parent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_2' id='input_13_2_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_13_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_13_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #f7977a; background-color:#ebebeb; cursor: url(https:\/\/cotegilbert.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_13_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_13_2_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_13_2_data' name='input_13_2_data' value=''><\/div><\/li><li id=\"field_13_172\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_172'>Print 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_172' id='input_13_172' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_13_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_13_33' type='text' value='05 avril 2026 09h20' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_13' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_13' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_13' id='gform_theme_13' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_13' id='gform_style_settings_13' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_13' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='13' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='nca0CemJ5yFEMFAnhQbHxWk01mkLXRWYKklkSIznWOphzFdUvsbxY63ZI4V44lKkyCU\/bgY2ocgKT6p5zTB6IhN7eJi4glFfvWTTkpaUVQ1Ng74=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_13' value='WyJ7XCI4OC4xXCI6XCJkNTRmM2NjNWU3MmEwNjhkMWI1YmQzYTJmNjBmNzM1ZVwiLFwiODguMlwiOlwiNDFmMTQxYjk3NWFhMDQ1MGFmMDlmODE2Mzg4MmNjZjFcIixcIjg4LjNcIjpcIjk2ZDM1NmM1NzNkNTA2Mjk4YTg5YWVmODhjNzZmMzhkXCIsXCIyNTcuMVwiOlwiZDU0ZjNjYzVlNzJhMDY4ZDFiNWJkM2EyZjYwZjczNWVcIixcIjI1Ny4yXCI6XCJkZWMzNGJkMGYyMGU3MGZhZjgxOWNlNDgxOWE3NDYxY1wiLFwiMjU3LjNcIjpcIjk2ZDM1NmM1NzNkNTA2Mjk4YTg5YWVmODhjNzZmMzhkXCJ9IiwiZGI5NjM0ZDQyNGQxNTRhN2UxMmI0YjZkNzExYmExY2MiXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_13' id='gform_target_page_number_13' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_13' id='gform_source_page_number_13' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 13, 'https:\/\/cotegilbert.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_13').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_13');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_13').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_13').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_13').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_13').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_13').val();gformInitSpinner( 13, 'https:\/\/cotegilbert.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [13, current_page]);window['gf_submitting_13'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_13').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [13]);window['gf_submitting_13'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_13').text());}else{jQuery('#gform_13').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"13\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_13\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_13\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_13\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 13, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n[vc_empty_space height=&#8221;30px&#8221; alter_height=&#8221;none&#8221; hide_on_desktop=&#8221;&#8221; hide_on_notebook=&#8221;&#8221; hide_on_tablet=&#8221;&#8221; hide_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651600970841{margin-top: -0.25rem !important;}&#8221;][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row full_width=&#8221;stretch_row_content_no_spaces&#8221;][vc_column][vc_single_image image=&#8221;2929&#8243; img_size=&#8221;full&#8221;][\/vc_column][\/vc_row][vc_row hide_bg_image_on_tablet=&#8221;&#8221; hide_bg_image_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651768514961{margin-top: 40px !important;margin-bottom: 80px !important;}&#8221;][vc_column][vc_empty_space height=&#8221;10px&#8221; alter_height=&#8221;none&#8221; hide_on_desktop=&#8221;&#8221; hide_on_notebook=&#8221;&#8221; hide_on_tablet=&#8221;&#8221; hide_on_mobile=&#8221;&#8221; css=&#8221;.vc_custom_1651580449948{margin-top: -0.25rem !important;}&#8221;][vc_custom_heading text=&#8221;Medical Form for New Patients&#8221; font_container=&#8221;tag:h2|font_size:45px|text_align:left|color:%23797979|line_height:45px&#8221; use_theme_fonts=&#8221;yes&#8221;][vc_column_text]You are a new patient? You must first complete a questionnaire collecting all details related to your health status prior to your first appointment. In order to accelerate the process, we invite you to&hellip;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3157","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/pages\/3157","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/comments?post=3157"}],"version-history":[{"count":5,"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/pages\/3157\/revisions"}],"predecessor-version":[{"id":3269,"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/pages\/3157\/revisions\/3269"}],"wp:attachment":[{"href":"https:\/\/cotegilbert.com\/en\/wp-json\/wp\/v2\/media?parent=3157"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}