{"id":1753,"date":"2020-08-03T00:39:19","date_gmt":"2020-08-03T04:39:19","guid":{"rendered":"https:\/\/cliniquemaxillo.com\/?page_id=1753"},"modified":"2024-05-08T11:56:50","modified_gmt":"2024-05-08T15:56:50","slug":"confidential-medical-questionnaire","status":"publish","type":"page","link":"https:\/\/cliniquemaxillo.com\/en\/protocole\/confidential-medical-questionnaire\/","title":{"rendered":"Confidential medical questionnaire"},"content":{"rendered":"[vc_row][vc_column][vc_column_text css=&#8221;.vc_custom_1599598993064{margin-bottom: 0px !important;}&#8221;]\n<div class=\"medical-form text-holder\"><span style=\"font-size: 24px; color: #22b3a9;\">Confidential medical questionnaire<\/span><br \/>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_17' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_17'  action='\/en\/wp-json\/wp\/v2\/pages\/1753\/' data-formid='17' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_17_41\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_41\" ><div style=\"background-color:#00ada1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATION<\/div><\/li><li id=\"field_17_13\" 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\"  data-js-reload=\"field_17_13\" ><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_17_13'>\n\t\t\t<li class='gchoice gchoice_17_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='M'  id='choice_17_13_0'    \/>\n\t\t\t\t<label for='choice_17_13_0' id='label_17_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_17_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='F'  id='choice_17_13_1'    \/>\n\t\t\t\t<label for='choice_17_13_1' id='label_17_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_11\" class=\"gfield gfield--type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_11\" ><label class='gfield_label gform-field-label' for='input_17_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_17_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_8\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_8\" ><label class='gfield_label gform-field-label' for='input_17_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_17_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_34\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_34\" ><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_17_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_17_34_1_container' >\n                                        <label for='input_17_34_1' id='input_17_34_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                        <input type='text' name='input_34.1' id='input_17_34_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_17_34_3_container' >\n                                    <label for='input_17_34_3' id='input_17_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_34.3' id='input_17_34_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_17_34_4_container' >\n                                        <label for='input_17_34_4' id='input_17_34_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                        <select name='input_34.4' id='input_17_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                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_17_34_5_container' >\n                                    <label for='input_17_34_5' id='input_17_34_5_label' class='gform-field-label gform-field-label--type-sub '>Postal code<\/label>\n                                    <input type='text' name='input_34.5' id='input_17_34_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_17_34_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_17_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\"  data-js-reload=\"field_17_36\" ><label class='gfield_label gform-field-label' for='input_17_36'>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_17_36' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_17_37\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_37\" ><label class='gfield_label gform-field-label' for='input_17_37'>Tel. work<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_17_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_17_38\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_38\" ><label class='gfield_label gform-field-label' for='input_17_38'>Other tel<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_17_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_17_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\"  data-js-reload=\"field_17_40\" ><label class='gfield_label gform-field-label' for='input_17_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_17_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_17_35\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_35\" ><label class='gfield_label gform-field-label' >Date of birth (DD\/MM\/YYYY)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_17_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_17_35_2_container'><select name='input_35[]' id='input_17_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_17_35_1_container'><select name='input_35[]' id='input_17_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_17_35_3_container'><select name='input_35[]' id='input_17_35_3'   aria-required='true'  ><option value=''>Year<\/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_17_44\" class=\"gfield gfield--type-text gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_44\" ><label class='gfield_label gform-field-label' for='input_17_44'>Medical number (optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_17_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_46\" class=\"gfield gfield--type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_46\" ><label class='gfield_label gform-field-label' for='input_17_46'>Expiration<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_17_46' type='text' value='' class='small'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_47\" class=\"gfield gfield--type-text gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_47\" ><label class='gfield_label gform-field-label' for='input_17_47'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_17_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_92\" class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_92\" ><label class='gfield_label gform-field-label' for='input_17_92'>Your dentist<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_17_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_123\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_123\" ><label class='gfield_label gform-field-label' for='input_17_123'>Your orthodontist<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_17_123' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_93\" 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\"  data-js-reload=\"field_17_93\" ><label class='gfield_label gform-field-label' for='input_17_93'>Reason for 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_93' id='input_17_93' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_124\" class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_124\" ><label class='gfield_label gform-field-label' for='input_17_124'>What I would like to correct<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_17_124' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_42\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_42\" ><br><br><div style=\"background-color:#00ada1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ARE YOU SUFFERING OR HAVE YOU SUFFERED FROM...?<\/div><\/li><li id=\"field_17_43\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline inline-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_43\" ><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_17_43'>\n\t\t\t<li class='gchoice gchoice_17_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Oui'  id='choice_17_43_0'    \/>\n\t\t\t\t<label for='choice_17_43_0' id='label_17_43_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_17_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Non'  id='choice_17_43_1'    \/>\n\t\t\t\t<label for='choice_17_43_1' id='label_17_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_16\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_16\" ><label class='gfield_label gform-field-label' >Infarction or angina<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_17_16'>\n\t\t\t<li class='gchoice gchoice_17_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Oui'  id='choice_17_16_0'    \/>\n\t\t\t\t<label for='choice_17_16_0' id='label_17_16_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_17_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Non'  id='choice_17_16_1'    \/>\n\t\t\t\t<label for='choice_17_16_1' id='label_17_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_52\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_52\" ><label class='gfield_label gform-field-label' >Endocarditis (heart infection)<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_17_52'>\n\t\t\t<li class='gchoice gchoice_17_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Oui'  id='choice_17_52_0'    \/>\n\t\t\t\t<label for='choice_17_52_0' id='label_17_52_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_17_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='Non'  id='choice_17_52_1'    \/>\n\t\t\t\t<label for='choice_17_52_1' id='label_17_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_53\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_53\" ><label class='gfield_label gform-field-label' >Valvular disease<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_17_53'>\n\t\t\t<li class='gchoice gchoice_17_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Oui'  id='choice_17_53_0'    \/>\n\t\t\t\t<label for='choice_17_53_0' id='label_17_53_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_17_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='Non'  id='choice_17_53_1'    \/>\n\t\t\t\t<label for='choice_17_53_1' id='label_17_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_54\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_54\" ><label class='gfield_label gform-field-label' >Heart murmur or Heart defect<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_17_54'>\n\t\t\t<li class='gchoice gchoice_17_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Oui'  id='choice_17_54_0'    \/>\n\t\t\t\t<label for='choice_17_54_0' id='label_17_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_17_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Non'  id='choice_17_54_1'    \/>\n\t\t\t\t<label for='choice_17_54_1' id='label_17_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_57\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_57\" ><label class='gfield_label gform-field-label' >High 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_17_57'>\n\t\t\t<li class='gchoice gchoice_17_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Oui'  id='choice_17_57_0'    \/>\n\t\t\t\t<label for='choice_17_57_0' id='label_17_57_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_17_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Non'  id='choice_17_57_1'    \/>\n\t\t\t\t<label for='choice_17_57_1' id='label_17_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_141\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_141\" ><label class='gfield_label gform-field-label' >Low 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_17_141'>\n\t\t\t<li class='gchoice gchoice_17_141_0'>\n\t\t\t\t<input name='input_141' type='radio' value='Oui'  id='choice_17_141_0'    \/>\n\t\t\t\t<label for='choice_17_141_0' id='label_17_141_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_17_141_1'>\n\t\t\t\t<input name='input_141' type='radio' value='Non'  id='choice_17_141_1'    \/>\n\t\t\t\t<label for='choice_17_141_1' id='label_17_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_55\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_55\" ><label class='gfield_label gform-field-label' >Thrombophlebitis \/ Pulmonary embolism<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_17_55'>\n\t\t\t<li class='gchoice gchoice_17_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Oui'  id='choice_17_55_0'    \/>\n\t\t\t\t<label for='choice_17_55_0' id='label_17_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_17_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='Non'  id='choice_17_55_1'    \/>\n\t\t\t\t<label for='choice_17_55_1' id='label_17_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_56\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_56\" ><label class='gfield_label gform-field-label' >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_17_56'>\n\t\t\t<li class='gchoice gchoice_17_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Oui'  id='choice_17_56_0'    \/>\n\t\t\t\t<label for='choice_17_56_0' id='label_17_56_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_17_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='Non'  id='choice_17_56_1'    \/>\n\t\t\t\t<label for='choice_17_56_1' id='label_17_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_58\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_58\" ><label class='gfield_label gform-field-label' >Asthma or Chronic obstructive pulmonary disease<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_17_58'>\n\t\t\t<li class='gchoice gchoice_17_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Oui'  id='choice_17_58_0'    \/>\n\t\t\t\t<label for='choice_17_58_0' id='label_17_58_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_17_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Non'  id='choice_17_58_1'    \/>\n\t\t\t\t<label for='choice_17_58_1' id='label_17_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_59\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_59\" ><label class='gfield_label gform-field-label' >Tuberculosis<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_17_59'>\n\t\t\t<li class='gchoice gchoice_17_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Oui'  id='choice_17_59_0'    \/>\n\t\t\t\t<label for='choice_17_59_0' id='label_17_59_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_17_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Non'  id='choice_17_59_1'    \/>\n\t\t\t\t<label for='choice_17_59_1' id='label_17_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_60\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_60\" ><label class='gfield_label gform-field-label' >Other pulmonary disease<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_17_60'>\n\t\t\t<li class='gchoice gchoice_17_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Oui'  id='choice_17_60_0'    \/>\n\t\t\t\t<label for='choice_17_60_0' id='label_17_60_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_17_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Non'  id='choice_17_60_1'    \/>\n\t\t\t\t<label for='choice_17_60_1' id='label_17_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_61\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_61\" ><label class='gfield_label gform-field-label' >Digestive disease<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_17_61'>\n\t\t\t<li class='gchoice gchoice_17_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='Oui'  id='choice_17_61_0'    \/>\n\t\t\t\t<label for='choice_17_61_0' id='label_17_61_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_17_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Non'  id='choice_17_61_1'    \/>\n\t\t\t\t<label for='choice_17_61_1' id='label_17_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_62\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_62\" ><label class='gfield_label gform-field-label' >Ulcer<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_17_62'>\n\t\t\t<li class='gchoice gchoice_17_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Oui'  id='choice_17_62_0'    \/>\n\t\t\t\t<label for='choice_17_62_0' id='label_17_62_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_17_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Non'  id='choice_17_62_1'    \/>\n\t\t\t\t<label for='choice_17_62_1' id='label_17_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_143\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_143\" ><label class='gfield_label gform-field-label' >Reflux<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_17_143'>\n\t\t\t<li class='gchoice gchoice_17_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Oui'  id='choice_17_143_0'    \/>\n\t\t\t\t<label for='choice_17_143_0' id='label_17_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_17_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='Non'  id='choice_17_143_1'    \/>\n\t\t\t\t<label for='choice_17_143_1' id='label_17_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_63\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_63\" ><label class='gfield_label gform-field-label' >Renal disease<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_17_63'>\n\t\t\t<li class='gchoice gchoice_17_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Oui'  id='choice_17_63_0'    \/>\n\t\t\t\t<label for='choice_17_63_0' id='label_17_63_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_17_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Non'  id='choice_17_63_1'    \/>\n\t\t\t\t<label for='choice_17_63_1' id='label_17_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_64\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_64\" ><label class='gfield_label gform-field-label' >Thyroid disease<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_17_64'>\n\t\t\t<li class='gchoice gchoice_17_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Oui'  id='choice_17_64_0'    \/>\n\t\t\t\t<label for='choice_17_64_0' id='label_17_64_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_17_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='Non'  id='choice_17_64_1'    \/>\n\t\t\t\t<label for='choice_17_64_1' id='label_17_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_65\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_65\" ><label class='gfield_label gform-field-label' >Liver disease<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_17_65'>\n\t\t\t<li class='gchoice gchoice_17_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Oui'  id='choice_17_65_0'    \/>\n\t\t\t\t<label for='choice_17_65_0' id='label_17_65_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_17_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='Non'  id='choice_17_65_1'    \/>\n\t\t\t\t<label for='choice_17_65_1' id='label_17_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_66\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_66\" ><label class='gfield_label gform-field-label' >Hepatitis or Other viral infection<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_17_66'>\n\t\t\t<li class='gchoice gchoice_17_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Oui'  id='choice_17_66_0'    \/>\n\t\t\t\t<label for='choice_17_66_0' id='label_17_66_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_17_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Non'  id='choice_17_66_1'    \/>\n\t\t\t\t<label for='choice_17_66_1' id='label_17_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_67\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_67\" ><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_17_67'>\n\t\t\t<li class='gchoice gchoice_17_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Oui'  id='choice_17_67_0'    \/>\n\t\t\t\t<label for='choice_17_67_0' id='label_17_67_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_17_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='Non'  id='choice_17_67_1'    \/>\n\t\t\t\t<label for='choice_17_67_1' id='label_17_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_68\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_68\" ><label class='gfield_label gform-field-label' >Epilepsy or Seizure<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_17_68'>\n\t\t\t<li class='gchoice gchoice_17_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Oui'  id='choice_17_68_0'    \/>\n\t\t\t\t<label for='choice_17_68_0' id='label_17_68_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_17_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='Non'  id='choice_17_68_1'    \/>\n\t\t\t\t<label for='choice_17_68_1' id='label_17_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_69\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_69\" ><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_17_69'>\n\t\t\t<li class='gchoice gchoice_17_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Oui'  id='choice_17_69_0'    \/>\n\t\t\t\t<label for='choice_17_69_0' id='label_17_69_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_17_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='Non'  id='choice_17_69_1'    \/>\n\t\t\t\t<label for='choice_17_69_1' id='label_17_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_146\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_146\" ><label class='gfield_label gform-field-label' >Cancer<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_17_146'>\n\t\t\t<li class='gchoice gchoice_17_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='Oui'  id='choice_17_146_0'    \/>\n\t\t\t\t<label for='choice_17_146_0' id='label_17_146_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_17_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='Non'  id='choice_17_146_1'    \/>\n\t\t\t\t<label for='choice_17_146_1' id='label_17_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_70\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_70\" ><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_17_70'>\n\t\t\t<li class='gchoice gchoice_17_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Oui'  id='choice_17_70_0'    \/>\n\t\t\t\t<label for='choice_17_70_0' id='label_17_70_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_17_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='Non'  id='choice_17_70_1'    \/>\n\t\t\t\t<label for='choice_17_70_1' id='label_17_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_145\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_145\" ><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_17_145'>\n\t\t\t<li class='gchoice gchoice_17_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Oui'  id='choice_17_145_0'    \/>\n\t\t\t\t<label for='choice_17_145_0' id='label_17_145_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_17_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='Non'  id='choice_17_145_1'    \/>\n\t\t\t\t<label for='choice_17_145_1' id='label_17_145_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_71\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_71\" ><label class='gfield_label gform-field-label' >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_17_71'>\n\t\t\t<li class='gchoice gchoice_17_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Oui'  id='choice_17_71_0'    \/>\n\t\t\t\t<label for='choice_17_71_0' id='label_17_71_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_17_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='Non'  id='choice_17_71_1'    \/>\n\t\t\t\t<label for='choice_17_71_1' id='label_17_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_89\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_89\" ><br><br><div style=\"background-color:#00ada1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">MEDICAL HISTORY<\/div><\/li><li id=\"field_17_72\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_72\" ><label class='gfield_label gform-field-label' >Are you or could you be 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_17_72'>\n\t\t\t<li class='gchoice gchoice_17_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Oui'  id='choice_17_72_0'    \/>\n\t\t\t\t<label for='choice_17_72_0' id='label_17_72_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_17_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Non'  id='choice_17_72_1'    \/>\n\t\t\t\t<label for='choice_17_72_1' id='label_17_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_85\" class=\"gfield gfield--type-checkbox gfield--type-choice checkbox-color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_85\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you allergic to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_17_85'><li class='gchoice gchoice_17_85_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.1' type='checkbox'  value='No known allergies'  id='choice_17_85_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_1' id='label_17_85_1' class='gform-field-label gform-field-label--type-inline'>No known allergies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.2' type='checkbox'  value='Penicillin'  id='choice_17_85_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_2' id='label_17_85_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_17_85_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.3' type='checkbox'  value='Sulfonamides'  id='choice_17_85_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_3' id='label_17_85_3' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.4' type='checkbox'  value='Aspirin'  id='choice_17_85_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_4' id='label_17_85_4' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.5' type='checkbox'  value='Codeine'  id='choice_17_85_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_5' id='label_17_85_5' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.6' type='checkbox'  value='Anti inflammatory'  id='choice_17_85_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_6' id='label_17_85_6' class='gform-field-label gform-field-label--type-inline'>Anti inflammatory<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.7' type='checkbox'  value='Latex'  id='choice_17_85_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_7' id='label_17_85_7' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_17_85_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.8' type='checkbox'  value='Other'  id='choice_17_85_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_17_85_8' id='label_17_85_8' 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_17_87\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_87\" ><label class='gfield_label gform-field-label' for='input_17_87'>Specify others<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_17_87' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_94\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_94\" ><label class='gfield_label gform-field-label' >Are you taking any medications or natural 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_17_94'>\n\t\t\t<li class='gchoice gchoice_17_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Oui'  id='choice_17_94_0'    \/>\n\t\t\t\t<label for='choice_17_94_0' id='label_17_94_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_17_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Non'  id='choice_17_94_1'    \/>\n\t\t\t\t<label for='choice_17_94_1' id='label_17_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_126\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_126\" ><label class='gfield_label gform-field-label' for='input_17_126'>If yes, which ones:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_17_126' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_127\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_127\" ><label class='gfield_label gform-field-label' >Have you taken cortisone in the last 6 months?<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_17_127'>\n\t\t\t<li class='gchoice gchoice_17_127_0'>\n\t\t\t\t<input name='input_127' type='radio' value='Oui'  id='choice_17_127_0'    \/>\n\t\t\t\t<label for='choice_17_127_0' id='label_17_127_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_17_127_1'>\n\t\t\t\t<input name='input_127' type='radio' value='Non'  id='choice_17_127_1'    \/>\n\t\t\t\t<label for='choice_17_127_1' id='label_17_127_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_128\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_128\" ><label class='gfield_label gform-field-label' >Have you undergone surgery?<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_17_128'>\n\t\t\t<li class='gchoice gchoice_17_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Oui'  id='choice_17_128_0'    \/>\n\t\t\t\t<label for='choice_17_128_0' id='label_17_128_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_17_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='Non'  id='choice_17_128_1'    \/>\n\t\t\t\t<label for='choice_17_128_1' id='label_17_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_129\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_129\" ><label class='gfield_label gform-field-label' for='input_17_129'>If yes, other than dental:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_17_129' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_130\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_130\" ><label class='gfield_label gform-field-label' >Have you ever 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_17_130'>\n\t\t\t<li class='gchoice gchoice_17_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='Oui'  id='choice_17_130_0'    \/>\n\t\t\t\t<label for='choice_17_130_0' id='label_17_130_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_17_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='Non'  id='choice_17_130_1'    \/>\n\t\t\t\t<label for='choice_17_130_1' id='label_17_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_131\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_131\" ><label class='gfield_label gform-field-label' for='input_17_131'>If yes, when and what for?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_17_131' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_135\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_135\" ><div style=\"background-color:#ffffff;color:#00ada1;font-weight:bold;font-size:18px;\">Are you taking\/using:<\/div><\/li><li id=\"field_17_132\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_132\" ><label class='gfield_label gform-field-label' >Tobacco 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_17_132'>\n\t\t\t<li class='gchoice gchoice_17_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Oui'  id='choice_17_132_0'    \/>\n\t\t\t\t<label for='choice_17_132_0' id='label_17_132_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_17_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='Non'  id='choice_17_132_1'    \/>\n\t\t\t\t<label for='choice_17_132_1' id='label_17_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_136\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_136\" ><label class='gfield_label gform-field-label' for='input_17_136'>If yes, number 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_136' id='input_17_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_133\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_133\" ><label class='gfield_label gform-field-label' >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_17_133'>\n\t\t\t<li class='gchoice gchoice_17_133_0'>\n\t\t\t\t<input name='input_133' type='radio' value='Oui'  id='choice_17_133_0'    \/>\n\t\t\t\t<label for='choice_17_133_0' id='label_17_133_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_17_133_1'>\n\t\t\t\t<input name='input_133' type='radio' value='Non'  id='choice_17_133_1'    \/>\n\t\t\t\t<label for='choice_17_133_1' id='label_17_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_137\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_137\" ><label class='gfield_label gform-field-label' for='input_17_137'>If yes, number per week:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_17_137' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_134\" class=\"gfield gfield--type-radio gfield--type-choice inline-radio gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_134\" ><label class='gfield_label gform-field-label' >Illicit 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_17_134'>\n\t\t\t<li class='gchoice gchoice_17_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Oui'  id='choice_17_134_0'    \/>\n\t\t\t\t<label for='choice_17_134_0' id='label_17_134_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_17_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Non'  id='choice_17_134_1'    \/>\n\t\t\t\t<label for='choice_17_134_1' id='label_17_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_17_138\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_138\" ><label class='gfield_label gform-field-label' for='input_17_138'>If yes, what kind?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_17_138' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_139\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_139\" ><label class='gfield_label gform-field-label' for='input_17_139'>Other health conditions not mentioned<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_17_139' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_17_91\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_91\" ><br><br><div style=\"background-color:#00ada1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div><\/li><li id=\"field_17_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\"  data-js-reload=\"field_17_88\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of medical history<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_17_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_17_88_1' >I, the undersigned, hereby declare that I have read, understook and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Clinique MFML. I have been informed that my file will be kept in the office at all the time and that only the dentist and it\u2019s auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.<\/label><input type='hidden' name='input_88.2' value='I, the undersigned, hereby declare that I have read, understook and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Clinique MFML. I have been informed that my file will be kept in the office at all the time and that only the dentist and it\u2019s auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='5' class='gform_hidden' \/><\/div><\/li><li id=\"field_17_90\" class=\"gfield gfield--type-consent gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_90\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Publication Acceptance<\/label><div class='ginput_container ginput_container_consent'><input name='input_90.1' id='input_17_90_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_17_90_1' >I consent for my photographs taken during my visit(s) to be used for teaching and publication puroses.<\/label><input type='hidden' name='input_90.2' value='I consent for my photographs taken during my visit(s) to be used for teaching and publication puroses.' class='gform_hidden' \/><input type='hidden' name='input_90.3' value='5' class='gform_hidden' \/><\/div><\/li><li id=\"field_17_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_2\" ><label class='gfield_label gform-field-label' for='input_17_2'>Patient or Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_17_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_17_2_valid' id='input_17_2_valid' \/><canvas id='input_17_2' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_17_147\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_147\" ><script type=\"text\/javascript\">\n    jQuery(document).ready(function($) {\n      var onclickAttr = $('.gform_save_link').attr('onclick');\n      onclickAttr = \"if(($('#input_17_2_data').val() == '') && ($('#input_17_2_signature_image').length == 0)) { alert('Please check the signature on the form'); } else {\" + onclickAttr + \"}\"\n      $('.gform_save_link').attr('onclick', onclickAttr);\n    });\n<\/script><\/li><li id=\"field_17_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_33\" ><label class='gfield_label gform-field-label' for='input_17_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_17_33' type='text' value='21 d\u00e9cembre 2024 03h29' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_110\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_110\" ><br><br><div style=\"background-color:#545454;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">RESERVED FOR ADMINISTRATION<\/div><\/li><li id=\"field_17_112\" class=\"gfield gfield--type-textarea grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_112\" ><label class='gfield_label gform-field-label' for='input_17_112'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_17_112' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_17_113\" class=\"gfield gfield--type-textarea grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_113\" ><label class='gfield_label gform-field-label' for='input_17_113'>Precautions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_17_113' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_17_111\" class=\"gfield gfield--type-consent gfield--type-choice grisadmin gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_111\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of the specialist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_111.1' id='input_17_111_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_17_111_1' >I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.<\/label><input type='hidden' name='input_111.2' value='I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.' class='gform_hidden' \/><input type='hidden' name='input_111.3' value='5' class='gform_hidden' \/><\/div><\/li><li id=\"field_17_117\" class=\"gfield gfield--type-signature grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_117\" ><label class='gfield_label gform-field-label' for='input_17_117'>Specialist Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_17_117_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_17_117_valid' id='input_17_117_valid' \/><canvas id='input_17_117' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_17_116\" class=\"gfield gfield--type-text grisadmin gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_116\" ><label class='gfield_label gform-field-label' for='input_17_116'>Specialist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_17_116' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_114\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon grisadmin field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_114\" ><label class='gfield_label gform-field-label' for='input_17_114'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_114' id='input_17_114' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_17_114_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_17_114_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_17_114' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_17_118\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_17_118\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_17_118'>is Approval<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_17_118' type='text' value='1' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_17_119\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_17_119\" ><label class='gfield_label gform-field-label' >Who is this for?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_17_119'>\n\t\t\t<li class='gchoice gchoice_17_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Me'  id='choice_17_119_0'    \/>\n\t\t\t\t<label for='choice_17_119_0' id='label_17_119_0' class='gform-field-label gform-field-label--type-inline'>Me<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_17' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_17\"]){return false;}  if( !jQuery(\"#gform_17\")[0].checkValidity || jQuery(\"#gform_17\")[0].checkValidity()){window[\"gf_submitting_17\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_17\"]){return false;} if( !jQuery(\"#gform_17\")[0].checkValidity || jQuery(\"#gform_17\")[0].checkValidity()){window[\"gf_submitting_17\"]=true;}  jQuery(\"#gform_17\").trigger(\"submit\",[true]); }' \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_17_footer_link' class='gform_save_link gform-theme-button gform-theme-button--secondary'  onclick='if(window[\"gf_submitting_17\"]){return false;}  if( !jQuery(\"#gform_17\")[0].checkValidity || jQuery(\"#gform_17\")[0].checkValidity()){window[\"gf_submitting_17\"]=true;} jQuery(\"#gform_save_17\").val(1); jQuery(\"#gform_17\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_17\"]){return false;} if( !jQuery(\"#gform_17\")[0].checkValidity || jQuery(\"#gform_17\")[0].checkValidity()){window[\"gf_submitting_17\"]=true;} jQuery(\"#gform_save_17\").val(1); jQuery(\"#gform_17\").trigger(\"submit\",[true]); }'> Send your information<\/a>\n            <input 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