{"id":3588,"date":"2025-11-18T15:08:07","date_gmt":"2025-11-18T20:08:07","guid":{"rendered":"https:\/\/cliniquemaxillo.com\/medical-questionnaire\/"},"modified":"2026-02-11T17:17:58","modified_gmt":"2026-02-11T22:17:58","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/cliniquemaxillo.com\/en\/medical-questionnaire\/","title":{"rendered":"Medical questionnaire"},"content":{"rendered":"    <section class=\"form || section\">\n        \n<span class=\"absolute top-0 left-0\" ><\/span>        <div class=\"wrapper || lg:grid-col\">\n                        <div class=\"max-lg:mt-8 || lg:col-start-2 lg:col-span-10 xxl:col-start-3 xxl:col-span-8\">\n                    <script type=\"text\/javascript\">\n        jQuery(document).ready(function($) {\n            \/\/ S'attacher \u00e0 l'\u00e9v\u00e9nement de soumission du formulaire ID 3\n            $('#gform_3').on('submit', function(e) {\n\n                \/\/ V\u00e9rifier si c'est le patient qui clique sur le bouton (action de sauvegarde)\n                if ($('#gform_save_3').val() === '1') {\n                    var isValid = true;\n\n                    \/\/ Nettoyer les erreurs visuelles pr\u00e9c\u00e9dentes\n                    $('#gform_3 .gfield_error').removeClass('gfield_error');\n\n                    \/\/ Parcourir tous les champs obligatoires qui sont actuellement visibles\n                    $('#gform_3 .gfield_contains_required:visible').each(function() {\n                        var $field = $(this);\n                        var isFieldValid = true;\n\n                        \/\/ Si c'est un groupe de boutons radio ou de cases \u00e0 cocher\n                        if ($field.find('input[type=\"radio\"], input[type=\"checkbox\"]').length > 0) {\n                            if ($field.find('input:checked').length === 0) {\n                                isFieldValid = false;\n                            }\n                        }\n                        \/\/ Si c'est un champ standard (texte, pr\u00e9nom\/nom, courriel, date)\n                        else {\n                            \/\/ On v\u00e9rifie tous les sous-champs visibles (ex: Pr\u00e9nom et Nom)\n                            $field.find('input:not([type=\"hidden\"]), select, textarea').each(function() {\n                                if ($.trim($(this).val()) === '') {\n                                    isFieldValid = false;\n                                }\n                            });\n                        }\n\n                        \/\/ Si le champ est vide, on ajoute la classe d'erreur native de GF\n                        if (!isFieldValid) {\n                            isValid = false;\n                            $field.addClass('gfield_error');\n                        }\n                    });\n\n                    \/\/ Si au moins un champ obligatoire est vide, on bloque l'envoi\n                    if (!isValid) {\n                        \/\/ L'alerte avec la traduction\n                        alert('Please fill in all required fields (highlighted in red) before submitting your information.');\n\n                        \/\/ Annuler l'action de sauvegarde\n                        $('#gform_save_3').val('');\n\n                        \/\/ D\u00c9VERROUILLER GRAVITY FORMS POUR PERMETTRE UNE NOUVELLE SOUMISSION\n                        window[\"gf_submitting_3\"] = false;\n\n                        e.preventDefault();\n                        e.stopImmediatePropagation();\n                        return false;\n                    }\n                }\n            });\n        });\n    <\/script>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/3588#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_3_80\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'>Phone<\/label><div class='gfield_description' id='gfield_description_3_80'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_80' id='input_3_80' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your information<\/h3><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_3'>\n\t\t\t<div class='gchoice gchoice_3_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='M'  id='choice_3_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_3_0' id='label_3_3_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='F'  id='choice_3_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_3_1' id='label_3_3_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_3_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Other'  id='choice_3_3_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_3_2' id='label_3_3_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_4\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_4'>\n                            \n                            <span id='input_3_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_4_3' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                    <input type='text' name='input_4.3' id='input_3_4_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_3_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_4_6' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                            <input type='text' name='input_4.6' id='input_3_4_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_5\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_5_1_container' >\n                                        <label for='input_3_5_1' id='input_3_5_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_5.1' id='input_3_5_1' value=''   placeholder='Mailing address' aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_5_3_container' >\n                                    <label for='input_3_5_3' id='input_3_5_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   placeholder='City' aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_5_4_container' >\n                                        <label for='input_3_5_4' id='input_3_5_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                        <input type='text' name='input_5.4' id='input_3_5_4' value=''     placeholder='Province' aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_5_5_container' >\n                                    <label for='input_3_5_5' id='input_3_5_5_label' class='gform-field-label gform-field-label--type-sub '>Postal code<\/label>\n                                    <input type='text' name='input_5.5' id='input_3_5_5' value=''   placeholder='Province' aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_3_5_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_3_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Cell phone <span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_3_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Work phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_3_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Other phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_3_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>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_9' id='input_3_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_3_10' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_10_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_10' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_3_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>Health insurance number (optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'>Expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Your dentist&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Your orthodontist&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>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_16' id='input_3_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>What I would like to correct<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Have you had, or do you have, any of the following?<\/h3><\/div><fieldset id=\"field_3_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_19'>\n\t\t\t<div class='gchoice gchoice_3_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_3_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_0' id='label_3_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_3_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Heart attack or angina<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_23'>\n\t\t\t<div class='gchoice gchoice_3_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_3_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_0' id='label_3_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_3_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_23_1' id='label_3_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Endocarditis (heart infection)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_22'>\n\t\t\t<div class='gchoice gchoice_3_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_3_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_3_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Heart valve abnormality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_21'>\n\t\t\t<div class='gchoice gchoice_3_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_3_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_0' id='label_3_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_3_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_21_1' id='label_3_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Heart murmur or congenital heart defect<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_20'>\n\t\t\t<div class='gchoice gchoice_3_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_3_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_0' id='label_3_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_3_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >High blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_26'>\n\t\t\t<div class='gchoice gchoice_3_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_3_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_0' id='label_3_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_3_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_26_1' id='label_3_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Low blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_25'>\n\t\t\t<div class='gchoice gchoice_3_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_3_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_25_0' id='label_3_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_3_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_25_1' id='label_3_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Thrombophlebitis \/ Pulmonary embolism<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_24'>\n\t\t\t<div class='gchoice gchoice_3_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_3_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_24_0' id='label_3_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_3_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_24_1' id='label_3_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hemorrhage, prolonged bleeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_32'>\n\t\t\t<div class='gchoice gchoice_3_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_3_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_0' id='label_3_32_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_3_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Asthma or chronic bronchitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_31'>\n\t\t\t<div class='gchoice gchoice_3_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_3_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_0' id='label_3_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_3_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_31_1' id='label_3_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tuberculosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_30'>\n\t\t\t<div class='gchoice gchoice_3_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Yes'  id='choice_3_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_30_0' id='label_3_30_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='No'  id='choice_3_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_30_1' id='label_3_30_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Other lung problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_29'>\n\t\t\t<div class='gchoice gchoice_3_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_3_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_29_0' id='label_3_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_3_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Digestive disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_28'>\n\t\t\t<div class='gchoice gchoice_3_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_3_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_28_0' id='label_3_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_3_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_28_1' id='label_3_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Ulcer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_27'>\n\t\t\t<div class='gchoice gchoice_3_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_3_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_0' id='label_3_27_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_3_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_27_1' id='label_3_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Reflux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_34'>\n\t\t\t<div class='gchoice gchoice_3_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Yes'  id='choice_3_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_34_0' id='label_3_34_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='No'  id='choice_3_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_34_1' id='label_3_34_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Kidney disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_35'>\n\t\t\t<div class='gchoice gchoice_3_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_3_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_35_0' id='label_3_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_3_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_35_1' id='label_3_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Thyroid disorder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_39'>\n\t\t\t<div class='gchoice gchoice_3_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Yes'  id='choice_3_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_0' id='label_3_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='No'  id='choice_3_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_39_1' id='label_3_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Liver problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_33'>\n\t\t\t<div class='gchoice gchoice_3_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_3_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_3_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Hepatitis or other viral disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_38'>\n\t\t\t<div class='gchoice gchoice_3_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_3_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_0' id='label_3_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_3_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Arthritis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_37'>\n\t\t\t<div class='gchoice gchoice_3_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_3_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_37_0' id='label_3_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_3_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_37_1' id='label_3_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Epilepsy or seizures<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_36'>\n\t\t\t<div class='gchoice gchoice_3_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Yes'  id='choice_3_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_36_0' id='label_3_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='No'  id='choice_3_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_36_1' id='label_3_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_40\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Osteoporosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_40'>\n\t\t\t<div class='gchoice gchoice_3_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_3_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_40_0' id='label_3_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_3_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_40_1' id='label_3_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Cancer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_41'>\n\t\t\t<div class='gchoice gchoice_3_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_3_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_41_0' id='label_3_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_3_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical history<\/h3><\/div><fieldset id=\"field_3_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Could you currently be pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_46'>\n\t\t\t<div class='gchoice gchoice_3_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_3_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_46_0' id='label_3_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_3_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever had an allergic reaction or other reaction to the following products:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_47'><div class='gchoice gchoice_3_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='No known allergies'  id='choice_3_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>No known allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Penicillin'  id='choice_3_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_2' id='label_3_47_2' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Sulfonamides'  id='choice_3_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_3' id='label_3_47_3' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Aspirin'  id='choice_3_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_4' id='label_3_47_4' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Codeine'  id='choice_3_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_5' id='label_3_47_5' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Anti-inflammatory'  id='choice_3_47_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_6' id='label_3_47_6' class='gform-field-label gform-field-label--type-inline'>Anti-inflammatory<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.7' type='checkbox'  value='Latex'  id='choice_3_47_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_7' id='label_3_47_7' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_47_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.8' type='checkbox'  value='Other'  id='choice_3_47_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_47_8' id='label_3_47_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_48'>Specify other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_3_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you take any medications or natural products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_50'>\n\t\t\t<div class='gchoice gchoice_3_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_3_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_0' id='label_3_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_3_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'>If yes, current list<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_3_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you taken cortisone in the past 6 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_51'>\n\t\t\t<div class='gchoice gchoice_3_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_3_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_51_0' id='label_3_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_3_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_52'>\n\t\t\t<div class='gchoice gchoice_3_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_3_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_3_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_55'>If yes, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_3_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been hospitalized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_53'>\n\t\t\t<div class='gchoice gchoice_3_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_3_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_3_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_57'>If yes, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_58\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Do you use:<\/h3><\/div><fieldset id=\"field_3_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tobacco<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_59'>\n\t\t\t<div class='gchoice gchoice_3_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_3_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_0' id='label_3_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_3_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_62'>If yes, indicate the number of cigarettes 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_62' id='input_3_62' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Alcohol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_61'>\n\t\t\t<div class='gchoice gchoice_3_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_3_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_61_0' id='label_3_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_3_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_61_1' id='label_3_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_60'>If yes, indicate the number of drinks 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_60' id='input_3_60' type='text' value='' class='large'    placeholder='If yes, indicate the number of drinks per week' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Drugs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_63'>\n\t\t\t<div class='gchoice gchoice_3_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_3_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_63_0' id='label_3_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_3_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_63_1' id='label_3_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'>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_64' id='input_3_64' type='text' value='' class='large'    placeholder='If yes, which ones?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consent<\/h3><\/div><fieldset id=\"field_3_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Medical history consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_66'><div class='gchoice gchoice_3_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='I, the undersigned, declare that I have read, understood, informed myself, and answered the medical-dental questionnaire to the best of my knowledge. I hereby agree to notify you of any change in my health status. I authorize the creation of my dental record, its follow-up, as well as my enrollment on the Clinique MFML recall list. I have been informed that my record will be kept at the office and that only the dentist and their staff will have access to it. I have been informed of my right to consult my record, request a correction, and withdraw from the recall list.    '  id='choice_3_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>I, the undersigned, declare that I have read, understood, informed myself, and answered the medical-dental questionnaire to the best of my knowledge. I hereby agree to notify you of any change in my health status. I authorize the creation of my dental record, its follow-up, as well as my enrollment on the Clinique MFML recall list. I have been informed that my record will be kept at the office and that only the dentist and their staff will have access to it. I have been informed of my right to consult my record, request a correction, and withdraw from the recall list.    <\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Publication consent<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_67'><div class='gchoice gchoice_3_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='I agree that the photos taken may be used for teaching and\/or publication purposes'  id='choice_3_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_67_1' id='label_3_67_1' class='gform-field-label gform-field-label--type-inline'>I agree that the photos taken may be used for teaching and\/or publication purposes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_79\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of transmission of information by e-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_79'><div class='gchoice gchoice_3_79_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.1' type='checkbox'  value='I agree that the information provided in this form may be sent by e-mail to the Clinique MFML team for the purposes of my care.'  id='choice_3_79_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_79_1' id='label_3_79_1' class='gform-field-label gform-field-label--type-inline'>I agree that the information provided in this form may be sent by e-mail to the Clinique MFML team for the purposes of my care.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_3_73' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_73_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_73_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_73' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_3_76\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Signature<\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_76' id='input_3_76_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_76_Container' class='gfield_signature_container' style='height:180px; width:1000px; ' ><canvas id=\"input_3_76\" width=\"1000\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_3_76_toolbar' style='margin:5px 0;position:relative;height:20px;width:1000px;max-width:100%;'><img id='input_3_76_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' role='button' tabindex='0' aria-label='Clear Signature' \/><\/div><input type='hidden' id='input_3_76_data' name='input_3_76_data' value=''><\/div><\/div><\/fieldset><div id=\"field_3_68\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">For the treating team only<\/h3><\/div><div id=\"field_3_69\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_69'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_3_69' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_70'>Precautions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_3_70' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Specialist consent<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_71'><div class='gchoice gchoice_3_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='I acknowledge that I have reviewed the answers on the registration questionnaire and have taken the usual measures, where applicable.'  id='choice_3_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_71_1' id='label_3_71_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have reviewed the answers on the registration questionnaire and have taken the usual measures, where applicable.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_74'>Specialist&#039;s name<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_3_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_72\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_72'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_72' id='input_3_72' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_72_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_72_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_72' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_75'>Other medical conditions not listed<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_3_75' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above 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_3_78'>Show hidden fields<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_3_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_77\" class=\"gfield gfield--type-hcaptcha gfield--input-type-hcaptcha gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_77'>hCaptcha<\/label>\t\t<input\n\t\t\t\ttype=\"hidden\"\n\t\t\t\tclass=\"hcaptcha-widget-id\"\n\t\t\t\tname=\"hcaptcha-widget-id\"\n\t\t\t\tvalue=\"eyJzb3VyY2UiOlsiZ3Jhdml0eWZvcm1zXC9ncmF2aXR5Zm9ybXMucGhwIl0sImZvcm1faWQiOjN9-36fa250a9ee4b0d9064db4aaf42d2a54\">\n\t\t\t\t<h-captcha\n\t\t\tclass=\"h-captcha\" 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