{"id":57,"date":"2020-06-02T09:38:21","date_gmt":"2020-06-02T13:38:21","guid":{"rendered":"https:\/\/parodontistemontreal.com\/protocole\/?page_id=57"},"modified":"2020-06-02T09:38:21","modified_gmt":"2020-06-02T13:38:21","slug":"questionnaire-medical-confidentiel","status":"publish","type":"page","link":"https:\/\/parodontistemontreal.com\/protocole\/questionnaire-medical-confidentiel\/","title":{"rendered":"Questionnaire m\u00e9dical confidentiel"},"content":{"rendered":"<p><span style=\"font-size: 24px; color: #cc0000;\">Questionnaire m\u00e9dical confidentiel<\/span><br \/>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_11'  action='\/protocole\/wp-json\/wp\/v2\/pages\/57' data-formid='11' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_11_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:#cc0000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">VOS INFORMATIONS<\/div><\/div><fieldset id=\"field_11_13\" 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\"  ><legend class='gfield_label gform-field-label' >Genre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_13'>\n\t\t\t<div class='gchoice gchoice_11_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='M'  id='choice_11_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_13_0' id='label_11_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_11_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='F'  id='choice_11_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_13_1' id='label_11_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_11\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_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_11_11'>Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_11_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_8\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_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_11_8'>Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_11_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_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' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_11_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_11_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_11_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_11_34_1' id='input_11_34_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_11_34_2_container' >\n                                        <input type='text' name='input_34.2' id='input_11_34_2' value=''     aria-required='false'   \/>\n                                        <label for='input_11_34_2' id='input_11_34_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_11_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_11_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_11_34_3' id='input_11_34_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_11_34_4_container' >\n                                        <select name='input_34.4' id='input_11_34_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' selected='selected'>Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_11_34_4' id='input_11_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_11_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_11_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_11_34_5' id='input_11_34_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_11_34_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_11_36\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_11_36'>T\u00e9l\u00e9phone domicile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_11_36' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_37\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_11_37'>T\u00e9l\u00e9phone bureau<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_11_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_38\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_11_38'>Cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_11_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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_11_40'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_11_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_11_35\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_right_half gfield--width-half 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' >Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_11_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_11_35_2_container'><label for='input_11_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Jour<\/label><select name='input_35[]' id='input_11_35_2'   aria-required='true'  ><option value=''>Jour<\/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_11_35_1_container'><label for='input_11_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mois<\/label><select name='input_35[]' id='input_11_35_1'   aria-required='true'  ><option value=''>Mois<\/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_11_35_3_container'><label for='input_11_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Ann\u00e9e<\/label><select name='input_35[]' id='input_11_35_3'   aria-required='true'  ><option value=''>Ann\u00e9e<\/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><div id=\"field_11_44\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_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_11_44'>Num\u00e9ro d&#039;assurance maladie (optionnel)<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_11_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_46\" class=\"gfield gfield--type-text gfield--input-type-text 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_11_46'>Expiration<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_11_46' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_47\" class=\"gfield gfield--type-text gfield--input-type-text 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_11_47'>Tuteur<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_11_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_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:#cc0000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">VOS ANT\u00c9C\u00c9DENTS M\u00c9DICAUX<\/div><\/div><fieldset id=\"field_11_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline 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' >\u00cates-vous suivi par un m\u00e9decin?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_15'>\n\t\t\t<div class='gchoice gchoice_11_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Oui'  id='choice_11_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_15_0' id='label_11_15_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Non'  id='choice_11_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_15_1' id='label_11_15_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_48\" 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_11_48'>Nom de votre m\u00e9decin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_11_48' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_49\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_11_49'>T\u00e9l\u00e9phone de votre m\u00e9decin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_11_49' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline 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' >Prenez-vous (pr\u00e9sentement) des m\u00e9dicaments ou en avez-vous pris au cours des 6 derniers mois?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_50'>\n\t\t\t<div class='gchoice gchoice_11_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Oui'  id='choice_11_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_0' id='label_11_50_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Non'  id='choice_11_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_50_1' id='label_11_50_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_51\" 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_11_51'>Si oui, lequels<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_11_51' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_43\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous eu une perte ou un gain marqu\u00e9 de poids derni\u00e8rement?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_43'>\n\t\t\t<div class='gchoice gchoice_11_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oui'  id='choice_11_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_43_0' id='label_11_43_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Non'  id='choice_11_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_43_1' id='label_11_43_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_16\" 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\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous enceinte?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_16'>\n\t\t\t<div class='gchoice gchoice_11_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Oui'  id='choice_11_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_16_0' id='label_11_16_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Non'  id='choice_11_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_16_1' id='label_11_16_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_52\" 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\"  ><legend class='gfield_label gform-field-label' >Prenez-vous des anovulants? (pilule anticonceptionnelle)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_52'>\n\t\t\t<div class='gchoice gchoice_11_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Oui'  id='choice_11_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_52_0' id='label_11_52_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Non'  id='choice_11_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_52_1' id='label_11_52_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_53\" 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\"  ><legend class='gfield_label gform-field-label' >Troubles cardiaques (infarctus, angine, probl\u00e8mes vasculaires, souffle)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_53'>\n\t\t\t<div class='gchoice gchoice_11_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Oui'  id='choice_11_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_53_0' id='label_11_53_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Non'  id='choice_11_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_53_1' id='label_11_53_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_54\" 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\"  ><legend class='gfield_label gform-field-label' >Fi\u00e8vre rhumatismale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_54'>\n\t\t\t<div class='gchoice gchoice_11_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Oui'  id='choice_11_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_54_0' id='label_11_54_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Non'  id='choice_11_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_54_1' id='label_11_54_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_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\"  ><legend class='gfield_label gform-field-label' >Saignements prolong\u00e9s<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_55'>\n\t\t\t<div class='gchoice gchoice_11_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Oui'  id='choice_11_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_0' id='label_11_55_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Non'  id='choice_11_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_55_1' id='label_11_55_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_56\" 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\"  ><legend class='gfield_label gform-field-label' >An\u00e9mie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_56'>\n\t\t\t<div class='gchoice gchoice_11_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Oui'  id='choice_11_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_56_0' id='label_11_56_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='Non'  id='choice_11_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_56_1' id='label_11_56_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_57\" 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\"  ><legend class='gfield_label gform-field-label' >Pression art\u00e9rielle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_57'>\n\t\t\t<div class='gchoice gchoice_11_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Oui - Haute'  id='choice_11_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_57_0' id='label_11_57_0' class='gform-field-label gform-field-label--type-inline'>Oui - Haute<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Oui - Basse'  id='choice_11_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_57_1' id='label_11_57_1' class='gform-field-label gform-field-label--type-inline'>Oui - Basse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_57_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non'  id='choice_11_57_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_57_2' id='label_11_57_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_58\" 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\"  ><legend class='gfield_label gform-field-label' >Rhumes fr\u00e9quents ou sinusites<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_58'>\n\t\t\t<div class='gchoice gchoice_11_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Oui'  id='choice_11_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_58_0' id='label_11_58_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Non'  id='choice_11_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_58_1' id='label_11_58_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_59\" 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\"  ><legend class='gfield_label gform-field-label' >Tuberculose \/ Probl\u00e8mes pulmonaires<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_59'>\n\t\t\t<div class='gchoice gchoice_11_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Oui'  id='choice_11_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_59_0' id='label_11_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Non'  id='choice_11_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_59_1' id='label_11_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_60\" 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\"  ><legend class='gfield_label gform-field-label' >Troubles digestifs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_60'>\n\t\t\t<div class='gchoice gchoice_11_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Oui'  id='choice_11_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_60_0' id='label_11_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Non'  id='choice_11_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_60_1' id='label_11_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_61\" 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\"  ><legend class='gfield_label gform-field-label' >Ulc\u00e8re d\u2019estomac<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_61'>\n\t\t\t<div class='gchoice gchoice_11_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Oui'  id='choice_11_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_61_0' id='label_11_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non'  id='choice_11_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_61_1' id='label_11_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_62\" 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\"  ><legend class='gfield_label gform-field-label' >Probl\u00e8me du foie (h\u00e9patite: virus A, B, C, cirrhose, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_62'>\n\t\t\t<div class='gchoice gchoice_11_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Oui'  id='choice_11_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_62_0' id='label_11_62_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Non'  id='choice_11_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_62_1' id='label_11_62_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_63\" 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\"  ><legend class='gfield_label gform-field-label' >Troubles du rein<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_63'>\n\t\t\t<div class='gchoice gchoice_11_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Oui'  id='choice_11_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_63_0' id='label_11_63_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Non'  id='choice_11_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_63_1' id='label_11_63_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_64\" 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\"  ><legend class='gfield_label gform-field-label' >Maladies transmissibles sexuellement (MTS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_64'>\n\t\t\t<div class='gchoice gchoice_11_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Oui'  id='choice_11_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_64_0' id='label_11_64_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Non'  id='choice_11_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_64_1' id='label_11_64_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_65\" 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\"  ><legend class='gfield_label gform-field-label' >Diab\u00e8te<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_65'>\n\t\t\t<div class='gchoice gchoice_11_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Oui'  id='choice_11_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_0' id='label_11_65_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Non'  id='choice_11_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_65_1' id='label_11_65_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_66\" 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\"  ><legend class='gfield_label gform-field-label' >Troubles thyro\u00efdiens<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_66'>\n\t\t\t<div class='gchoice gchoice_11_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Oui'  id='choice_11_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_66_0' id='label_11_66_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Non'  id='choice_11_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_66_1' id='label_11_66_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_67\" 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\"  ><legend class='gfield_label gform-field-label' >Maladie de la peau<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_67'>\n\t\t\t<div class='gchoice gchoice_11_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Oui'  id='choice_11_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_67_0' id='label_11_67_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Non'  id='choice_11_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_67_1' id='label_11_67_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_68\" 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\"  ><legend class='gfield_label gform-field-label' >Probl\u00e8mes oculaires (yeux)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_68'>\n\t\t\t<div class='gchoice gchoice_11_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Oui'  id='choice_11_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_68_0' id='label_11_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Non'  id='choice_11_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_68_1' id='label_11_68_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_69\" 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\"  ><legend class='gfield_label gform-field-label' >Arthrite<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_69'>\n\t\t\t<div class='gchoice gchoice_11_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Oui'  id='choice_11_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_69_0' id='label_11_69_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Non'  id='choice_11_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_69_1' id='label_11_69_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_70\" 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\"  ><legend class='gfield_label gform-field-label' >\u00c9pilepsie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_70'>\n\t\t\t<div class='gchoice gchoice_11_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Oui'  id='choice_11_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_70_0' id='label_11_70_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Non'  id='choice_11_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_70_1' id='label_11_70_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_71\" 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\"  ><legend class='gfield_label gform-field-label' >Troubles nerveux<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_71'>\n\t\t\t<div class='gchoice gchoice_11_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Oui'  id='choice_11_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_71_0' id='label_11_71_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Non'  id='choice_11_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_71_1' id='label_11_71_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_72\" 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\"  ><legend class='gfield_label gform-field-label' >Maux de t\u00eate fr\u00e9quents<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_72'>\n\t\t\t<div class='gchoice gchoice_11_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Oui'  id='choice_11_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_72_0' id='label_11_72_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Non'  id='choice_11_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_72_1' id='label_11_72_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_73\" 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\"  ><legend class='gfield_label gform-field-label' >\u00c9tourdissements, \u00e9vanouissements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_73'>\n\t\t\t<div class='gchoice gchoice_11_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Oui'  id='choice_11_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_73_0' id='label_11_73_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Non'  id='choice_11_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_73_1' id='label_11_73_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_74\" 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\"  ><legend class='gfield_label gform-field-label' >Maux d\u2019oreilles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_74'>\n\t\t\t<div class='gchoice gchoice_11_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Oui'  id='choice_11_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_74_0' id='label_11_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Non'  id='choice_11_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_74_1' id='label_11_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_75\" 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\"  ><legend class='gfield_label gform-field-label' >Rhume des foins<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_75'>\n\t\t\t<div class='gchoice gchoice_11_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Oui'  id='choice_11_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_75_0' id='label_11_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Non'  id='choice_11_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_75_1' id='label_11_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_76\" 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\"  ><legend class='gfield_label gform-field-label' >Asthme<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_76'>\n\t\t\t<div class='gchoice gchoice_11_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Oui'  id='choice_11_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_76_0' id='label_11_76_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Non'  id='choice_11_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_76_1' id='label_11_76_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_77\" 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\"  ><legend class='gfield_label gform-field-label' >Fumez-vous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_77'>\n\t\t\t<div class='gchoice gchoice_11_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Oui'  id='choice_11_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_77_0' id='label_11_77_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Non'  id='choice_11_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_77_1' id='label_11_77_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_78\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 subi des traitements de radioth\u00e9rapie ou de chimioth\u00e9rapie (tumeur)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_78'>\n\t\t\t<div class='gchoice gchoice_11_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Oui'  id='choice_11_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_78_0' id='label_11_78_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Non'  id='choice_11_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_78_1' id='label_11_78_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_79\" 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\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous atteint du sida?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_79'>\n\t\t\t<div class='gchoice gchoice_11_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Oui'  id='choice_11_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_79_0' id='label_11_79_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Non'  id='choice_11_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_79_1' id='label_11_79_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_80\" 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\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous s\u00e9ropositif?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_80'>\n\t\t\t<div class='gchoice gchoice_11_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Oui'  id='choice_11_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_80_0' id='label_11_80_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Non'  id='choice_11_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_80_1' id='label_11_80_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_81\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous des proth\u00e8ses articulaires (hanche, genou, etc,)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_81'>\n\t\t\t<div class='gchoice gchoice_11_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Oui'  id='choice_11_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_81_0' id='label_11_81_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Non'  id='choice_11_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_81_1' id='label_11_81_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_82\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 ou subi des interventions chirurgicales autres que dentaires?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_82'>\n\t\t\t<div class='gchoice gchoice_11_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Oui'  id='choice_11_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_82_0' id='label_11_82_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Non'  id='choice_11_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_82_1' id='label_11_82_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_83\" 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_11_83'>Si oui, lequelles et quand?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_11_83' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline 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' >Devez-vous prendre des antibiotiques avant les traitements dentaires?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_84'>\n\t\t\t<div class='gchoice gchoice_11_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Oui'  id='choice_11_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_84_0' id='label_11_84_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Non'  id='choice_11_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_84_1' id='label_11_84_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_85\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Avez-vous d\u00e9j\u00e0 eu une r\u00e9action allergique ou autre aux produits suivants:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_85'><div class='gchoice gchoice_11_85_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.1' type='checkbox'  value='Aliments'  id='choice_11_85_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_1' id='label_11_85_1' class='gform-field-label gform-field-label--type-inline'>Aliments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.2' type='checkbox'  value='Aspirine'  id='choice_11_85_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_2' id='label_11_85_2' class='gform-field-label gform-field-label--type-inline'>Aspirine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.3' type='checkbox'  value='P\u00e9nicilline'  id='choice_11_85_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_3' id='label_11_85_3' class='gform-field-label gform-field-label--type-inline'>P\u00e9nicilline<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.4' type='checkbox'  value='Iode'  id='choice_11_85_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_4' id='label_11_85_4' class='gform-field-label gform-field-label--type-inline'>Iode<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.5' type='checkbox'  value='Sulfamides'  id='choice_11_85_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_5' id='label_11_85_5' class='gform-field-label gform-field-label--type-inline'>Sulfamides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.6' type='checkbox'  value='Cod\u00e9ine'  id='choice_11_85_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_6' id='label_11_85_6' class='gform-field-label gform-field-label--type-inline'>Cod\u00e9ine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.7' type='checkbox'  value='Anesth\u00e9sie locale'  id='choice_11_85_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_7' id='label_11_85_7' class='gform-field-label gform-field-label--type-inline'>Anesth\u00e9sie locale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.8' type='checkbox'  value='Autre antibiotiques'  id='choice_11_85_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_8' id='label_11_85_8' class='gform-field-label gform-field-label--type-inline'>Autre antibiotiques<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_85_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_85.9' type='checkbox'  value='Autres'  id='choice_11_85_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_85_9' id='label_11_85_9' class='gform-field-label gform-field-label--type-inline'>Autres<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_86\" 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_11_86'>Sp\u00e9cifiez autres antibiotiques<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_11_86' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_87\" 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_11_87'>Sp\u00e9cifiez autres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_11_87' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_89\" 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:#cc0000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">HISTORIQUE DENTAIRE<\/div><\/div><div id=\"field_11_92\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_92'>Nom du dentiste r\u00e9f\u00e9rent<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_11_92' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_11_93\" 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_11_93'>Raison de la visite<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_11_93' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_126\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Est-ce que vous fumez?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_126'><div class='gchoice gchoice_11_126_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.1' type='checkbox'  value='Oui Tabac'  id='choice_11_126_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_126_1' id='label_11_126_1' class='gform-field-label gform-field-label--type-inline'>Oui Tabac<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_126_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.2' type='checkbox'  value='Oui Cannabis'  id='choice_11_126_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_126_2' id='label_11_126_2' class='gform-field-label gform-field-label--type-inline'>Oui Cannabis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_126_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.3' type='checkbox'  value='Oui Vapotage'  id='choice_11_126_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_126_3' id='label_11_126_3' class='gform-field-label gform-field-label--type-inline'>Oui Vapotage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_126_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.4' type='checkbox'  value='Non'  id='choice_11_126_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_126_4' id='label_11_126_4' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_95\" 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_11_95'>Si oui, combien de cigarettes par jour et depuis combien de temps?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_11_95' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_96\" 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\"  ><legend class='gfield_label gform-field-label' >Est-ce que vos gencives saignent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_96'>\n\t\t\t<div class='gchoice gchoice_11_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Oui'  id='choice_11_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_96_0' id='label_11_96_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Non'  id='choice_11_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_96_1' id='label_11_96_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_97\" 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\"  ><legend class='gfield_label gform-field-label' >Est ce que vos dents sont sensibles?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_97'>\n\t\t\t<div class='gchoice gchoice_11_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Oui'  id='choice_11_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_97_0' id='label_11_97_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Non'  id='choice_11_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_97_1' id='label_11_97_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_98\" 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\"  ><legend class='gfield_label gform-field-label' >Est-ce que vos dents se d\u00e9chaussent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_98'>\n\t\t\t<div class='gchoice gchoice_11_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Oui'  id='choice_11_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_98_0' id='label_11_98_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Non'  id='choice_11_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_98_1' id='label_11_98_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_99\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous not\u00e9 un d\u00e9placement de vos dents?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_99'>\n\t\t\t<div class='gchoice gchoice_11_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Oui'  id='choice_11_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_99_0' id='label_11_99_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Non'  id='choice_11_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_99_1' id='label_11_99_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_100\" 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\"  ><legend class='gfield_label gform-field-label' >Sentez-vous que vos dents bougent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_100'>\n\t\t\t<div class='gchoice gchoice_11_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Oui'  id='choice_11_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_100_0' id='label_11_100_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Non'  id='choice_11_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_100_1' id='label_11_100_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_101\" 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\"  ><legend class='gfield_label gform-field-label' >Est-ce que la nourriture reste coinc\u00e9e entre vos dents?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_101'>\n\t\t\t<div class='gchoice gchoice_11_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Oui'  id='choice_11_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_101_0' id='label_11_101_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Non'  id='choice_11_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_101_1' id='label_11_101_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_102\" 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\"  ><legend class='gfield_label gform-field-label' >Grincez-vous des dents ou les serrez-vous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_102'>\n\t\t\t<div class='gchoice gchoice_11_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Oui'  id='choice_11_102_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_102_0' id='label_11_102_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Non'  id='choice_11_102_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_102_1' id='label_11_102_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_122\" 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_11_122'>Combien de fois vous brossez-vous les dents chaque jour?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_11_122' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_105\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Utilisez-vous ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_105'><div class='gchoice gchoice_11_105_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_105.1' type='checkbox'  value='Une brosse \u00e0 dents manuelle'  id='choice_11_105_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_105_1' id='label_11_105_1' class='gform-field-label gform-field-label--type-inline'>Une brosse \u00e0 dents manuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_105_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_105.2' type='checkbox'  value='Une brosse \u00e0 dents \u00e9lectrique'  id='choice_11_105_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_105_2' id='label_11_105_2' class='gform-field-label gform-field-label--type-inline'>Une brosse \u00e0 dents \u00e9lectrique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_105_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_105.3' type='checkbox'  value='La soie dentaire'  id='choice_11_105_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_105_3' id='label_11_105_3' class='gform-field-label gform-field-label--type-inline'>La soie dentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_105_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_105.4' type='checkbox'  value='Les brossettes interdentaires'  id='choice_11_105_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_105_4' id='label_11_105_4' class='gform-field-label gform-field-label--type-inline'>Les brossettes interdentaires<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_107\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 re\u00e7u des traitements dentaires?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_107'>\n\t\t\t<div class='gchoice gchoice_11_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Oui'  id='choice_11_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_107_0' id='label_11_107_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Non'  id='choice_11_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_107_1' id='label_11_107_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_106\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Si oui, lequels<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_106'><div class='gchoice gchoice_11_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Surfa\u00e7age'  id='choice_11_106_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_1' id='label_11_106_1' class='gform-field-label gform-field-label--type-inline'>Surfa\u00e7age<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='Surfa\u00e7age gingivale'  id='choice_11_106_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_2' id='label_11_106_2' class='gform-field-label gform-field-label--type-inline'>Surfa\u00e7age gingivale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.3' type='checkbox'  value='Greffe gingivale'  id='choice_11_106_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_3' id='label_11_106_3' class='gform-field-label gform-field-label--type-inline'>Greffe gingivale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.4' type='checkbox'  value='Implants'  id='choice_11_106_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_4' id='label_11_106_4' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.5' type='checkbox'  value='Greffe osseuse'  id='choice_11_106_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_5' id='label_11_106_5' class='gform-field-label gform-field-label--type-inline'>Greffe osseuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.6' type='checkbox'  value='R\u00e9g\u00e9n\u00e9ration tissulaire guid\u00e9e'  id='choice_11_106_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_6' id='label_11_106_6' class='gform-field-label gform-field-label--type-inline'>R\u00e9g\u00e9n\u00e9ration tissulaire guid\u00e9e<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.7' type='checkbox'  value='Obturations'  id='choice_11_106_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_7' id='label_11_106_7' class='gform-field-label gform-field-label--type-inline'>Obturations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.8' type='checkbox'  value='Proth\u00e8ses fixes'  id='choice_11_106_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_8' id='label_11_106_8' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses fixes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.9' type='checkbox'  value='Proth\u00e8ses amovibles'  id='choice_11_106_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_9' id='label_11_106_9' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses amovibles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.11' type='checkbox'  value='D\u00e9tartrage'  id='choice_11_106_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_11' id='label_11_106_11' class='gform-field-label gform-field-label--type-inline'>D\u00e9tartrage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.12' type='checkbox'  value='Traitement de canal'  id='choice_11_106_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_12' id='label_11_106_12' class='gform-field-label gform-field-label--type-inline'>Traitement de canal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_11_106_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.13' type='checkbox'  value='Plaque occlusale'  id='choice_11_106_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_106_13' id='label_11_106_13' class='gform-field-label gform-field-label--type-inline'>Plaque occlusale<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_11_108\" 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\"  ><legend class='gfield_label gform-field-label' >Est-ce que les traitements dentaires vous inqui\u00e8tent?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_108'>\n\t\t\t<div class='gchoice gchoice_11_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Oui'  id='choice_11_108_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_108_0' id='label_11_108_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Non'  id='choice_11_108_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_108_1' id='label_11_108_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_109\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_11_109'>D\u00e9crivez bri\u00e8vement votre inqui\u00e9tude<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_11_109' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_121\" 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\"  ><legend class='gfield_label gform-field-label' >Avez-vous un autre probl\u00e8me de sant\u00e9 non mentionn\u00e9 pr\u00e9c\u00e9demment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_121'>\n\t\t\t<div class='gchoice gchoice_11_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Oui'  id='choice_11_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_121_0' id='label_11_121_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_11_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Non'  id='choice_11_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_11_121_1' id='label_11_121_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_120\" 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_11_120'>D\u00e9crivez-nous votre probl\u00e8me de sant\u00e9<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_11_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_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\"  ><br><br><div style=\"background-color:#cc0000;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTATION<\/div><\/div><fieldset id=\"field_11_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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation historique m\u00e9dicale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_11_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_11_88_1' >Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dicodentaire au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.  J\u2019autorise la constitution de mon dossier dentaire, son suivi, ainsi que mon inscription sur la liste de rappel de Parodontiste Montr\u00e9al. On m\u2019a inform\u00e9 que mon dossier sera conserv\u00e9 au cabinet et que seul le dentiste et ses employ\u00e9s y auront acc\u00e8s. On m\u2019a inform\u00e9 de mon droit de consulter mon dossier, d\u2019y demander une rectification et de me retirer de la liste de rappel.<\/label><input type='hidden' name='input_88.2' value='Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dicodentaire au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.  J\u2019autorise la constitution de mon dossier dentaire, son suivi, ainsi que mon inscription sur la liste de rappel de Parodontiste Montr\u00e9al. On m\u2019a inform\u00e9 que mon dossier sera conserv\u00e9 au cabinet et que seul le dentiste et ses employ\u00e9s y auront acc\u00e8s. On m\u2019a inform\u00e9 de mon droit de consulter mon dossier, d\u2019y demander une rectification et de me retirer de la liste de rappel.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_90\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation historique dentaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_90.1' id='input_11_90_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_11_90_1' >Je, soussign\u00e9, d\u00e9clare avoir r\u00e9pondu \u00e0 ce questionnaire au meilleur de ma connaissance et m\u2019\u00eatre renseign\u00e9 aupr\u00e8s de mon dentiste si certains points n\u2019\u00e9taient pas clairs. Je comprends que le but de ce questionnaire est de parvenir aux meilleurs r\u00e9sultats possible.<\/label><input type='hidden' name='input_90.2' value='Je, soussign\u00e9, d\u00e9clare avoir r\u00e9pondu \u00e0 ce questionnaire au meilleur de ma connaissance et m\u2019\u00eatre renseign\u00e9 aupr\u00e8s de mon dentiste si certains points n\u2019\u00e9taient pas clairs. Je comprends que le but de ce questionnaire est de parvenir aux meilleurs r\u00e9sultats possible.' class='gform_hidden' \/><input type='hidden' name='input_90.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_127\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Acceptation collecte d&#039;informations personnelles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_127.1' id='input_11_127_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_11_127_1' >Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l'utilisation et \u00e0 la divulgation de mes renseignements personnels par PARODONTISTE MONTR\u00c9AL dans le but de fournir des services dentaires.<\/label><input type='hidden' name='input_127.2' value='Par la pr\u00e9sente je donne mon consentement \u00e0 la collecte, \u00e0 l&#039;utilisation et \u00e0 la divulgation de mes renseignements personnels par PARODONTISTE MONTR\u00c9AL dans le but de fournir des services dentaires.' class='gform_hidden' \/><input type='hidden' name='input_127.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_129\" 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\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Politique d&#039;annulation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_129.1' id='input_11_129_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_11_129_1' >J'ai lu et je consens \u00e0 la politique d'annulation suivante: En cas d'annulation de votre rendez-vous, un pr\u00e9avis de 48 heures ouvrables est exig\u00e9 sans quoi des frais de 85$ vous seront factur\u00e9s.<\/label><input type='hidden' name='input_129.2' value='J&#039;ai lu et je consens \u00e0 la politique d&#039;annulation suivante: En cas d&#039;annulation de votre rendez-vous, un pr\u00e9avis de 48 heures ouvrables est exig\u00e9 sans quoi des frais de 85$ vous seront factur\u00e9s.' class='gform_hidden' \/><input type='hidden' name='input_129.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_11_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_11_2'>Signature du patient ou du responsable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_2' id='input_11_2_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_11_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_11_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #ee1d24; background-color:#ebebeb; cursor: url(https:\/\/parodontistemontreal.com\/protocole\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_11_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_11_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_11_2_data' name='input_11_2_data' value=''><\/div><\/div><div id=\"field_11_33\" class=\"gfield gfield--type-text gfield--input-type-text gf_readonly gf_left_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_11_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_11_33' type='text' value='27 avril 2026 14h21' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_124\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_right_half blanc gfield--width-half 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' >Administration<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_124'><div class='gchoice gchoice_11_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='R\u00e9serv\u00e9 \u00e0 l&#039;administration'  id='choice_11_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_11_124_1' id='label_11_124_1' class='gform-field-label gform-field-label--type-inline'>R\u00e9serv\u00e9 \u00e0 l'administration<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_11_110\" 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 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