{"id":17812,"date":"2026-07-29T09:56:24","date_gmt":"2026-07-29T13:56:24","guid":{"rendered":"https:\/\/santedentairegrandeallee.com\/questionnaire-medico-dentaire\/"},"modified":"2026-07-29T10:51:17","modified_gmt":"2026-07-29T14:51:17","slug":"questionnaire-medico-dentaire","status":"publish","type":"page","link":"https:\/\/santedentairegrandeallee.com\/en\/questionnaire-medico-dentaire\/","title":{"rendered":"Medical Dental Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"17812\" class=\"elementor elementor-17812 elementor-17806\">\n\t\t\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-8071f79 elementor-section-full_width elementor-section-height-min-height elementor-section-items-stretch elementor-section-content-middle elementor-section-height-default\" data-id=\"8071f79\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4a7cfac\" data-id=\"4a7cfac\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-element elementor-element-97b3ddd elementor-position-top elementor-view-default elementor-mobile-position-top elementor-vertical-align-top elementor-widget elementor-widget-icon-box\" data-id=\"97b3ddd\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<link rel=\"stylesheet\" href=\"https:\/\/santedentairegrandeallee.com\/wp-content\/uploads\/elementor\/css\/custom-widget-icon-box.min.css?ver=1788469071\">\t\t<div class=\"elementor-icon-box-wrapper\">\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span class=\"elementor-icon elementor-animation-\" >\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-pencil-alt\"><\/i>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t<span  >\n\t\t\t\t\t\tComplete the medical-dental questionnaire\t\t\t\t\t<\/span>\n\t\t\t\t<\/h3>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a9a9018 elementor-widget elementor-widget-text-editor\" data-id=\"a9a9018\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.6.5 - 27-04-2022 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#818a91;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#818a91;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p style=\"text-align: center;\"><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_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/en\/wp-json\/wp\/v2\/pages\/17812' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_258\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_258'><span class='gform-field-label__text'>LinkedIn<\/span><\/label><div class='ginput_container'><input name='input_258' id='input_5_258' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_258'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#87A6A1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR INFORMATIONS<\/div><\/div><div id=\"field_5_173\" class=\"gfield gfield--type-text gfield--input-type-text rougerouge field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_173'><span class='gform-field-label__text'>* Veuillez porter attention<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_5_173' type='text' value='* OUI * ' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_5_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'><span class='gform-field-label__text'>Last Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_175\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_175'><span class='gform-field-label__text'>Age<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_5_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_5_35' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_35_2_container'><label for='input_5_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_5_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_5_35_1_container'><label for='input_5_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_5_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_5_35_3_container'><label for='input_5_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_5_35_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Gender<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_13'>\n\t\t\t<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='M'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_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_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='F'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_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_5_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Other'  id='choice_5_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_2' id='label_5_13_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_123\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_123'><span class='gform-field-label__text'>Health Ins. No.<\/span><\/label><div class='gfield_description' id='gfield_description_5_123'>(To be completed for children aged 10 and under)<\/div><div class='ginput_container ginput_container_text'><input name='input_123' id='input_5_123' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_123\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_254\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_254'><span class='gform-field-label__text'>Expiration<\/span><\/label><div class='gfield_description' id='gfield_description_5_254'>(MM\/YYYY)<\/div><div class='ginput_container ginput_container_text'><input name='input_254' id='input_5_254' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_254\"    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_36'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_5_36' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_5_38' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_5_37' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_5_34\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_5_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_34_1' id='input_5_34_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_5_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_34_3' id='input_5_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_34_4_container' >\n                                        <select name='input_34.4' id='input_5_34_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_34_4' id='input_5_34_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_5_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_34_5' id='input_5_34_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_5_34_6' value='CA' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_5_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you under 18?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_126'>\n\t\t\t<div class='gchoice gchoice_5_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Yes'  id='choice_5_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_126_0' id='label_5_126_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_5_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='No'  id='choice_5_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_126_1' id='label_5_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_46\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'><span class='gform-field-label__text'>Father&#039;s Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_127\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_127'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_127' id='input_5_127' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_128\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_128'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_5_128' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_129\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_129'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_5_129' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_130\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_130'><span class='gform-field-label__text'>Mother&#039;s Name<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_5_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_133\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_133'><span class='gform-field-label__text'>Home Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_133' id='input_5_133' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_132\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_middle_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_132'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_5_132' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_131\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_third gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_131'><span class='gform-field-label__text'>Work Tel.<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_5_131' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><fieldset id=\"field_5_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Who is responsible for the fees?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_134'>\n\t\t\t<div class='gchoice gchoice_5_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Father'  id='choice_5_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_134_0' id='label_5_134_0' class='gform-field-label gform-field-label--type-inline'>Father<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Mother'  id='choice_5_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_134_1' id='label_5_134_1' class='gform-field-label gform-field-label--type-inline'>Mother<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_134_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Other'  id='choice_5_134_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_134_2' id='label_5_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_47\" class=\"gfield gfield--type-text gfield--input-type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'><span class='gform-field-label__text'>Specify Other<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_5_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_179\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>For emergencies, call:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name no_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_179'>\n                            \n                            <span id='input_5_179_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.3' id='input_5_179_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_179_3' class='gform-field-label gform-field-label--type-sub '>Name<\/label>\n                                                <\/span>\n                            <span id='input_5_179_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_179.4' id='input_5_179_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_179_4' class='gform-field-label gform-field-label--type-sub '>Relationship to patient<\/label>\n                                                <\/span>\n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_5_180\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_180'><span class='gform-field-label__text'>Main Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_180' id='input_5_180' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_181\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_181'><span class='gform-field-label__text'>Mobile<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_181' id='input_5_181' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#87A6A1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL INFORMATION<\/div><\/div><div id=\"field_5_139\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_139'><span class='gform-field-label__text'>Reason for today\u2019s visit<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_5_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Last visit :<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_15'>\n\t\t\t<div class='gchoice gchoice_5_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='0-6 month'  id='choice_5_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_0' id='label_5_15_0' class='gform-field-label gform-field-label--type-inline'>0-6 month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='6-12 month'  id='choice_5_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>6-12 month<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='+12 month'  id='choice_5_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_15_2' id='label_5_15_2' class='gform-field-label gform-field-label--type-inline'>+12 month<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_182\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_182'><span class='gform-field-label__text'>Treatment(s) received<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_5_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With panoramic radiographs (large x-ray)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_142'>\n\t\t\t<div class='gchoice gchoice_5_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_5_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_142_0' id='label_5_142_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_5_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_5_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_142_1' id='label_5_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>With intraoral radiographs (small x-rays)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_143'>\n\t\t\t<div class='gchoice gchoice_5_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='Yes'  id='choice_5_143_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_143_0' id='label_5_143_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_5_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='No'  id='choice_5_143_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_143_1' id='label_5_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you fear dental treatments?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_145'>\n\t\t\t<div class='gchoice gchoice_5_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Not at all'  id='choice_5_145_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_145_0' id='label_5_145_0' class='gform-field-label gform-field-label--type-inline'>Not at all<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='A little'  id='choice_5_145_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_145_1' id='label_5_145_1' class='gform-field-label gform-field-label--type-inline'>A little<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_145_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Very much'  id='choice_5_145_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_145_2' id='label_5_145_2' class='gform-field-label gform-field-label--type-inline'>Very much<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_136\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_136'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_5_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Would you like to speak privately with your dentist?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_183'>\n\t\t\t<div class='gchoice gchoice_5_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Yes'  id='choice_5_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_183_0' id='label_5_183_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_5_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='No'  id='choice_5_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_183_1' id='label_5_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_184\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_184'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_5_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you being treated by a physician?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_185'>\n\t\t\t<div class='gchoice gchoice_5_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Yes'  id='choice_5_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_185_0' id='label_5_185_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_5_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='No'  id='choice_5_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_185_1' id='label_5_185_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_186\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_186'><span class='gform-field-label__text'>Physician&#039;s Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_5_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_256\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_256'><span class='gform-field-label__text'>Physician Tel.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_256' id='input_5_256' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_5_255\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_255'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_5_255' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you ever had surgery or been hospitalized?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_187'>\n\t\t\t<div class='gchoice gchoice_5_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='Yes'  id='choice_5_187_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_187_0' id='label_5_187_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_5_187_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='No'  id='choice_5_187_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_187_1' id='label_5_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_188\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_188'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_5_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you have joint prostheses (hip, knee, etc.)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_189'>\n\t\t\t<div class='gchoice gchoice_5_189_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='Yes'  id='choice_5_189_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_189_0' id='label_5_189_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_5_189_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='No'  id='choice_5_189_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_189_1' id='label_5_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_190\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_190'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_5_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_191\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Have you gained or lost a lot of weight recently?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_191'>\n\t\t\t<div class='gchoice gchoice_5_191_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_191' type='radio' value='Yes'  id='choice_5_191_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_191_0' id='label_5_191_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_5_191_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_191' type='radio' value='No'  id='choice_5_191_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_191_1' id='label_5_191_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_192\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_192'><span class='gform-field-label__text'>Reason, details and date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_5_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking natural or homeopathic products?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_193'>\n\t\t\t<div class='gchoice gchoice_5_193_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='Yes'  id='choice_5_193_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_193_0' id='label_5_193_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_5_193_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='No'  id='choice_5_193_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_193_1' id='label_5_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_194\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_194'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_5_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you pregnant?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_195'>\n\t\t\t<div class='gchoice gchoice_5_195_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='Yes'  id='choice_5_195_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_195_0' id='label_5_195_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_5_195_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='No'  id='choice_5_195_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_195_1' id='label_5_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you breastfeeding?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_196'>\n\t\t\t<div class='gchoice gchoice_5_196_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='Yes'  id='choice_5_196_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_196_0' id='label_5_196_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_5_196_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_196' type='radio' value='No'  id='choice_5_196_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_196_1' id='label_5_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_197\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking medication?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_197'>\n\t\t\t<div class='gchoice gchoice_5_197_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='Yes'  id='choice_5_197_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_197_0' id='label_5_197_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_5_197_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='No'  id='choice_5_197_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_197_1' id='label_5_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you taking birth control or hormones<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_198'>\n\t\t\t<div class='gchoice gchoice_5_198_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes birth control'  id='choice_5_198_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_198_0' id='label_5_198_0' class='gform-field-label gform-field-label--type-inline'>Yes birth control<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_198_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes hormones'  id='choice_5_198_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_198_1' id='label_5_198_1' class='gform-field-label gform-field-label--type-inline'>Yes hormones<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_198_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='No'  id='choice_5_198_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_198_2' id='label_5_198_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_199\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_199'><span class='gform-field-label__text'>Please indicate all medication (including birth control and hormones) that you are taking or have taken in the last 12 months<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_199' id='input_5_199' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_138\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#87A6A1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">YOUR CURRENT CONDITION<\/div><\/div><div id=\"field_5_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;font-weight:bold;font-size:16px;\">Blood disorders<\/div><\/div><fieldset id=\"field_5_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>(hemophilia, anemia, prolonged bleeding)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_55'>\n\t\t\t<div class='gchoice gchoice_5_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_5_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_55_0' id='label_5_55_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_5_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_5_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;font-weight:bold;font-size:16px;\">Heart conditions<\/div><\/div><fieldset id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Infarction (heart attack), angina, surgery, etc.<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_54'>\n\t\t\t<div class='gchoice gchoice_5_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_5_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_0' id='label_5_54_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_5_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_5_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Heart infection (endocarditis)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_202'>\n\t\t\t<div class='gchoice gchoice_5_202_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='Yes'  id='choice_5_202_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_202_0' id='label_5_202_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_5_202_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='No'  id='choice_5_202_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_202_1' id='label_5_202_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_203\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Surgery to replace or repair a valve \/cusp<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_203'>\n\t\t\t<div class='gchoice gchoice_5_203_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='Yes'  id='choice_5_203_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_203_0' id='label_5_203_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_5_203_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='No'  id='choice_5_203_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_203_1' id='label_5_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_204\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;font-weight:bold;font-size:16px;\">Other<\/div><\/div><fieldset id=\"field_5_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Blood pressure<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_57'>\n\t\t\t<div class='gchoice gchoice_5_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes - Low'  id='choice_5_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_57_0' id='label_5_57_0' class='gform-field-label gform-field-label--type-inline'>Yes &#8211; Low<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes - High'  id='choice_5_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_57_1' id='label_5_57_1' class='gform-field-label gform-field-label--type-inline'>Yes &#8211; High<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_5_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_57_2' id='label_5_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Dizziness, fainting<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_205'>\n\t\t\t<div class='gchoice gchoice_5_205_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='Yes'  id='choice_5_205_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_205_0' id='label_5_205_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_5_205_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='No'  id='choice_5_205_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_205_1' id='label_5_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Frequent headaches<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_206'>\n\t\t\t<div class='gchoice gchoice_5_206_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='Yes'  id='choice_5_206_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_206_0' id='label_5_206_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_5_206_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_206' type='radio' value='No'  id='choice_5_206_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_206_1' id='label_5_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_207\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Jaw pain<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_207'>\n\t\t\t<div class='gchoice gchoice_5_207_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='Yes'  id='choice_5_207_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_207_0' id='label_5_207_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_5_207_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='No'  id='choice_5_207_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_207_1' id='label_5_207_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Liver disorders (hepatitis A, B, C. cirrhosis, etc.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_208'>\n\t\t\t<div class='gchoice gchoice_5_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='Yes'  id='choice_5_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_208_0' id='label_5_208_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_5_208_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='No'  id='choice_5_208_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_208_1' id='label_5_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Digestive system disorders or diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_209'>\n\t\t\t<div class='gchoice gchoice_5_209_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Yes'  id='choice_5_209_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_209_0' id='label_5_209_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_5_209_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='No'  id='choice_5_209_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_209_1' id='label_5_209_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_210\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_210'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_5_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_211\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Stomach disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_211'>\n\t\t\t<div class='gchoice gchoice_5_211_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='Yes, Ulcer'  id='choice_5_211_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_211_0' id='label_5_211_0' class='gform-field-label gform-field-label--type-inline'>Yes, Ulcer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_211_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='Yes, Reflux'  id='choice_5_211_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_211_1' id='label_5_211_1' class='gform-field-label gform-field-label--type-inline'>Yes, Reflux<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_211_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_211' type='radio' value='No'  id='choice_5_211_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_211_2' id='label_5_211_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_212\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Kidney disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_212'>\n\t\t\t<div class='gchoice gchoice_5_212_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='Yes'  id='choice_5_212_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_212_0' id='label_5_212_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_5_212_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_212' type='radio' value='No'  id='choice_5_212_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_212_1' id='label_5_212_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_213\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Diabetes<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_213'>\n\t\t\t<div class='gchoice gchoice_5_213_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='Yes'  id='choice_5_213_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_213_0' id='label_5_213_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_5_213_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_213' type='radio' value='No'  id='choice_5_213_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_213_1' id='label_5_213_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_214\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Thyroid disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_214'>\n\t\t\t<div class='gchoice gchoice_5_214_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='Yes'  id='choice_5_214_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_214_0' id='label_5_214_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_5_214_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_214' type='radio' value='No'  id='choice_5_214_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_214_1' id='label_5_214_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_217\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Cancer (tumour)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_217'>\n\t\t\t<div class='gchoice gchoice_5_217_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_217' type='radio' value='Yes'  id='choice_5_217_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_217_0' id='label_5_217_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_5_217_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_217' type='radio' value='No'  id='choice_5_217_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_217_1' id='label_5_217_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_218\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_218'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_5_218' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Radiotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_219'>\n\t\t\t<div class='gchoice gchoice_5_219_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='Yes'  id='choice_5_219_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_219_0' id='label_5_219_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_5_219_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_219' type='radio' value='No'  id='choice_5_219_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_219_1' id='label_5_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_220\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chemotherapy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_220'>\n\t\t\t<div class='gchoice gchoice_5_220_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='Yes'  id='choice_5_220_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_220_0' id='label_5_220_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_5_220_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='No'  id='choice_5_220_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_220_1' id='label_5_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you suffer from dry mouth?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_221'>\n\t\t\t<div class='gchoice gchoice_5_221_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='Yes'  id='choice_5_221_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_221_0' id='label_5_221_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_5_221_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='No'  id='choice_5_221_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_221_1' id='label_5_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_222\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sexually transmitted or blood-borne infections (STBBI)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_222'>\n\t\t\t<div class='gchoice gchoice_5_222_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_222' type='radio' value='Yes'  id='choice_5_222_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_222_0' id='label_5_222_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_5_222_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_222' type='radio' value='No'  id='choice_5_222_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_222_1' id='label_5_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_223\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_223'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_5_223' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_224\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Skin diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_224'>\n\t\t\t<div class='gchoice gchoice_5_224_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_224' type='radio' value='Yes'  id='choice_5_224_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_224_0' id='label_5_224_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_5_224_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_224' type='radio' value='No'  id='choice_5_224_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_224_1' id='label_5_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Eye disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_225'>\n\t\t\t<div class='gchoice gchoice_5_225_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='Yes'  id='choice_5_225_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_225_0' id='label_5_225_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_5_225_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='No'  id='choice_5_225_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_225_1' id='label_5_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_226\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Earaches<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_226'>\n\t\t\t<div class='gchoice gchoice_5_226_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_226' type='radio' value='Yes'  id='choice_5_226_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_226_0' id='label_5_226_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_5_226_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_226' type='radio' value='No'  id='choice_5_226_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_226_1' id='label_5_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_227\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Arthritis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_227'>\n\t\t\t<div class='gchoice gchoice_5_227_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_227' type='radio' value='Yes'  id='choice_5_227_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_227_0' id='label_5_227_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_5_227_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_227' type='radio' value='No'  id='choice_5_227_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_227_1' id='label_5_227_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Chronic pain<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_231'>\n\t\t\t<div class='gchoice gchoice_5_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='Yes'  id='choice_5_231_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_231_0' id='label_5_231_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_5_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='No'  id='choice_5_231_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_231_1' id='label_5_231_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_232\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Epilepsy<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_232'>\n\t\t\t<div class='gchoice gchoice_5_232_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='Yes'  id='choice_5_232_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_232_0' id='label_5_232_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_5_232_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='No'  id='choice_5_232_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_232_1' id='label_5_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_235\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Frequent colds or sinusitis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_235'>\n\t\t\t<div class='gchoice gchoice_5_235_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='Yes'  id='choice_5_235_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_235_0' id='label_5_235_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_5_235_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_235' type='radio' value='No'  id='choice_5_235_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_235_1' id='label_5_235_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_237\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Asthma<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_237'>\n\t\t\t<div class='gchoice gchoice_5_237_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_237' type='radio' value='Yes'  id='choice_5_237_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_237_0' id='label_5_237_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_5_237_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_237' type='radio' value='No'  id='choice_5_237_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_237_1' id='label_5_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Hay fever \/ seasonal allergies<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_238'>\n\t\t\t<div class='gchoice gchoice_5_238_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='Yes'  id='choice_5_238_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_238_0' id='label_5_238_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_5_238_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='No'  id='choice_5_238_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_238_1' id='label_5_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Tuberculosis or lung disorders<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_236'>\n\t\t\t<div class='gchoice gchoice_5_236_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='Yes'  id='choice_5_236_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_236_0' id='label_5_236_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_5_236_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='No'  id='choice_5_236_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_236_1' id='label_5_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_233\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Nervous system disorders or diseases<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_233'>\n\t\t\t<div class='gchoice gchoice_5_233_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='Yes'  id='choice_5_233_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_233_0' id='label_5_233_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_5_233_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_233' type='radio' value='No'  id='choice_5_233_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_233_1' id='label_5_233_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Mental disorders or illnesses<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_234'>\n\t\t\t<div class='gchoice gchoice_5_234_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='Yes'  id='choice_5_234_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_234_0' id='label_5_234_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_5_234_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='No'  id='choice_5_234_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_234_1' id='label_5_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_228\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Osteoporosis<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_228'>\n\t\t\t<div class='gchoice gchoice_5_228_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='Yes'  id='choice_5_228_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_228_0' id='label_5_228_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_5_228_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='No'  id='choice_5_228_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_228_1' id='label_5_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Annual or monthly injection<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_230'>\n\t\t\t<div class='gchoice gchoice_5_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Yes'  id='choice_5_230_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_230_0' id='label_5_230_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_5_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='No'  id='choice_5_230_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_230_1' id='label_5_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_229\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Prevention \/ treatment (e.g.: tablets)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_229'>\n\t\t\t<div class='gchoice gchoice_5_229_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='Yes'  id='choice_5_229_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_229_0' id='label_5_229_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_5_229_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='No'  id='choice_5_229_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_229_1' id='label_5_229_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_240\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Allergy or manifestation with products containing:<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_240'><div class='gchoice gchoice_5_240_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.1' type='checkbox'  value='Latex'  id='choice_5_240_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_1' id='label_5_240_1' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.2' type='checkbox'  value='Penicillin'  id='choice_5_240_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_2' id='label_5_240_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_5_240_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.3' type='checkbox'  value='Other antibiotics'  id='choice_5_240_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_3' id='label_5_240_3' class='gform-field-label gform-field-label--type-inline'>Other antibiotics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.4' type='checkbox'  value='Codeine'  id='choice_5_240_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_4' id='label_5_240_4' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.5' type='checkbox'  value='Aspirin'  id='choice_5_240_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_5' id='label_5_240_5' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.6' type='checkbox'  value='Sulfonamides'  id='choice_5_240_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_6' id='label_5_240_6' class='gform-field-label gform-field-label--type-inline'>Sulfonamides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.7' type='checkbox'  value='Anesthetic'  id='choice_5_240_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_7' id='label_5_240_7' class='gform-field-label gform-field-label--type-inline'>Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.8' type='checkbox'  value='Food'  id='choice_5_240_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_8' id='label_5_240_8' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.9' type='checkbox'  value='Iodine-containing products'  id='choice_5_240_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_9' id='label_5_240_9' class='gform-field-label gform-field-label--type-inline'>Iodine-containing products<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_240_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.11' type='checkbox'  value='Other'  id='choice_5_240_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_240_11' id='label_5_240_11' 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_5_241\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_241'><span class='gform-field-label__text'>Specify<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_5_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_120\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gf_left field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_120'><span class='gform-field-label__text'>Other medical conditions that should be mentioned<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_5_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_242\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#ffffff;color:#545454;font-weight:bold;font-size:16px;\">Other aspects<\/div><\/div><fieldset id=\"field_5_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you snore?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_243'>\n\t\t\t<div class='gchoice gchoice_5_243_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='Yes'  id='choice_5_243_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_243_0' id='label_5_243_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_5_243_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='No'  id='choice_5_243_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_243_1' id='label_5_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you suffer from sleep apnea?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_244'>\n\t\t\t<div class='gchoice gchoice_5_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='Yes'  id='choice_5_244_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_244_0' id='label_5_244_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_5_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='No'  id='choice_5_244_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_244_1' id='label_5_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you smoke?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_245'>\n\t\t\t<div class='gchoice gchoice_5_245_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Yes'  id='choice_5_245_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_245_0' id='label_5_245_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_5_245_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='No'  id='choice_5_245_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_245_1' id='label_5_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_245_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Ex-smoker'  id='choice_5_245_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_245_2' id='label_5_245_2' class='gform-field-label gform-field-label--type-inline'>Ex-smoker<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_246\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_246'><span class='gform-field-label__text'>How many cigarettes do you smoke per day?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_246' id='input_5_246' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you drink alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_247'>\n\t\t\t<div class='gchoice gchoice_5_247_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='Yes'  id='choice_5_247_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_247_0' id='label_5_247_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_5_247_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='No'  id='choice_5_247_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_247_1' id='label_5_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_250\" class=\"gfield gfield--type-text gfield--input-type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_250'><span class='gform-field-label__text'>The number of drinks &#8211; per day, week or month:<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_250' id='input_5_250' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_left_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you take drugs?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_252'>\n\t\t\t<div class='gchoice gchoice_5_252_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='Yes'  id='choice_5_252_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_252_0' id='label_5_252_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_5_252_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='No'  id='choice_5_252_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_252_1' id='label_5_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_253\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_middle_third gf_list_inline gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Do you take methadone?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_253'>\n\t\t\t<div class='gchoice gchoice_5_253_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='Yes'  id='choice_5_253_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_253_0' id='label_5_253_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_5_253_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_253' type='radio' value='No'  id='choice_5_253_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_253_1' id='label_5_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#87A6A1;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div><\/div><fieldset id=\"field_5_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Dental and medical history acceptance<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_5_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_5_88_1' ><span class='gform-field-label__text'>I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.<\/span><\/label><input type='hidden' name='input_88.2' value='I, the undersigned, declare that I have read, understood and answered the above questionnaire to the best of my knowledge.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_257\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Acceptance of Collection, use, and disclosure of personal information<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_257.1' id='input_5_257_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_257\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_257_1' ><span class='gform-field-label__text'>I hereby give my consent to the collection, use and disclosure of my personal information by SANT\u00c9 DENTAIRE GRANDE-ALL\u00c9E for the purpose of providing dental services.<\/span><\/label><input type='hidden' name='input_257.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by SANT\u00c9 DENTAIRE GRANDE-ALL\u00c9E for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_257.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_257'><div class='gfield_consent_description_text' tabindex='0'><span style=\"font-size:14px;\">More information about your <a href=\"https:\/\/santedentairegrandeallee.com\/en\/renseignements-personnels-collectes\/\" target=\"_blank\" rel=\"noopener noreferrer\">personal information collected<\/a><br \/>\nMore information about our <a href=\"https:\/\/santedentairegrandeallee.com\/en\/politique-de-confidentialite\/\" target=\"_blank\" rel=\"noopener noreferrer\">Privacy Policy<\/a><\/span><\/div><\/div><\/fieldset><div id=\"field_5_2\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_2'><span class='gform-field-label__text'>Signature of patient or parent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><input type='hidden' value='' name='input_2' id='input_5_2_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_5_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #6d928c; background-color:#dbeae7; cursor: url(https:\/\/santedentairegrandeallee.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_5_2_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_5_2_data' name='input_5_2_data' value=''><\/div><\/div><div id=\"field_5_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_172'><span class='gform-field-label__text'>Print Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_5_172' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_33'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='bKB0EEeT8hCmauq0lRXzzarmcgnYKGauWavr1PpJVz2JCzwU53emIE0sTvJ2bMFxh3+vfOlWNWQ8biqd3+jVkqKqBCxRnVXrt8R5B1jelN3tOmo=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_5' 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