{"id":79,"date":"2020-06-04T15:11:52","date_gmt":"2020-06-04T19:11:52","guid":{"rendered":"https:\/\/parodontistemontreal.com\/protocole_en_en\/confidential-medical-questionnaire\/"},"modified":"2020-06-04T15:15:19","modified_gmt":"2020-06-04T19:15:19","slug":"confidential-medical-questionnaire","status":"publish","type":"page","link":"https:\/\/parodontistemontreal.com\/protocole_en\/","title":{"rendered":"Confidential medical questionnaire"},"content":{"rendered":"<p><span style=\"font-size: 24px; color: #cc0000;\">Confidential medical questionnaire<\/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_en\/wp-json\/wp\/v2\/pages\/79' 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;\">YOUR 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' >Sex<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'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_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'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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' >Address<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 '>Address Street<\/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 '>Apt.<\/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 '>City<\/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 '>Postal Code<\/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'>Telephone residence<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'>Telephone office<\/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'>Cell Phone<\/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'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_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' >Birth Date<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'>Day<\/label><select name='input_35[]' id='input_11_35_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_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'>Month<\/label><select name='input_35[]' id='input_11_35_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_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'>Year<\/label><select name='input_35[]' id='input_11_35_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><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'>Social Insurance no. (optionnal)<\/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'>Guardian<\/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;\">YOUR MEDICAL HISTORY<\/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' >Are you followed by a doctor?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>Doctor&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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'>Doctor&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_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' >Are you presently taking any drug or medication, or have you taken any in the last six months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>If yes, which ones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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' >Did you recently experience a significant weight loss or gain?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Are you taking any bith control pill?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Hearth disease (stroke, angina, valvular problem, murmur)<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Rheumatic fever<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Prolonged bleeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Anemia<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes - High'  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'>Yes - High<\/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='Yes - Low'  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'>Yes - Low<\/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='No'  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'>No<\/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' >Frequent colds or sinusitis<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Tuberculosis or lung problems<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Digestive problems<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Stomach ulcer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Liver disease (Hepatitis A, B, C, cirrhosis, 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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Kidney disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Sexually transmitted diseases<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Thyroid problems<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Skin disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Eye problems<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Arthritis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Epilepsy<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Nervous disorders<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Frequent headaches<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Dizzy spells or fainting spells<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Earaches<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Hay fever<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Asthma<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you smoke?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Have you ever had radiotherapy or\/and chemotherapy treatment (tumor)<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you have AIDS symptoms?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Are you and AIDS virus carrier?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you have artificial joints?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Were you ever hospitalized or have you undergone surgery other than dental?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>If yes, which ones and when?<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' >Do you have to take antibiotics before dental treatments?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you have any of the following allergies?<\/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='Food'  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'>Food<\/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='Aspirin'  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'>Aspirin<\/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='Penicillin'  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'>Penicillin<\/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='Iodine'  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'>Iodine<\/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='Sulfonamides'  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'>Sulfonamides<\/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='Codeine'  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'>Codeine<\/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='Local anesthesia'  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'>Local anesthesia<\/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='Other antibiotics'  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'>Other antibiotics<\/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='Others'  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'>Others<\/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'>Specify other antibiotics<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'>Specify others<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_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;\">DENTAL HISTORY<\/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'>Name of refering dentist<\/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'>Reason for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_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' >Do you smoke?<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='Yes - Tobacco'  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'>Yes - Tobacco<\/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='Yes - 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'>Yes - 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='Yes - Vaping'  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'>Yes - Vaping<\/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='No'  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'>No<\/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'>If yes how many cigarettes per day and since when?<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' >Do your gums bleed?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you have sensitive teeth?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you have exposed roots?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Have you noticed a movement in your teeth?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you feel you teeth moving?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Does food lodge itself between your teeth?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >Do you grind or tighten you teeth together?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>How many times do you brush you teeth per day?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_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' >Do you use<\/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='A manual toothbrush'  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'>A manual toothbrush<\/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='A electric toothbrush'  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'>A electric toothbrush<\/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='Dental floss'  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'>Dental floss<\/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='Interdental brushes'  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'>Interdental brushes<\/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' >Have you received prior dental treatments?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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' >If yes, which ones<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='Scaling'  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'>Scaling<\/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='Root planing'  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'>Root planing<\/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='Gum graft'  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'>Gum graft<\/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='Bone graft'  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'>Bone graft<\/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='Regeneration of guided tissue'  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'>Regeneration of guided tissue<\/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='Filling'  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'>Filling<\/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='Amovable prothesis'  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'>Amovable prothesis<\/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='Fixed prothesis'  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'>Fixed prothesis<\/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='Cleaning'  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'>Cleaning<\/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='Root 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'>Root 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='Occlusal plate'  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'>Occlusal plate<\/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' >Do dental treatments worry you?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>Briefly describe your concern<\/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' >Do you have another health problem not mentioned previously?<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='Yes'  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'>Yes<\/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='No'  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'>No<\/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'>Tell us about your health problem<\/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;\">ACCEPTANCE<\/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' >Acceptance of medical history<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' >I, the undersigned, hereby declare that I have read, understook and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Parodontiste Montreal. I have been informed that my file will be kept in the office at all the time and that only the dentist and it\u2019s auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.<\/label><input type='hidden' name='input_88.2' value='I, the undersigned, hereby declare that I have read, understook and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health. I authorize the setting up of my dental file, its follow-up, as well as my registration on the recall list(s) of Parodontiste Montreal. I have been informed that my file will be kept in the office at all the time and that only the dentist and it\u2019s auxiliary personnel will have access to it. I have also been informed of my right to consult my file, to request that it be corrected, if necessary, and to remove my name from the recall list.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='4' 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' >Acceptance of dental history<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' >I, the undersigned, declare that I answered the questions to the best of my knowledge. I was also able and took the time to ask doctor all the questions I had regarding the present intervention. I understand, that the object of this questionnaire is to obtain the best results possible.<\/label><input type='hidden' name='input_90.2' value='I, the undersigned, declare that I answered the questions to the best of my knowledge. I was also able and took the time to ask doctor all the questions I had regarding the present intervention. I understand, that the object of this questionnaire is to obtain the best results possible.' class='gform_hidden' \/><input type='hidden' name='input_90.3' value='4' 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' >Acceptance of Collection, use, and disclosure of personal information<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' >I hereby give my consent to the collection, use and disclosure of my personal information by PARODONTISTE MONTR\u00c9AL for the purpose of providing dental services.<\/label><input type='hidden' name='input_127.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by PARODONTISTE MONTR\u00c9AL for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_127.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_11_128\" 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' >Cancellation policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_128.1' id='input_11_128_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_128_1' >I have read and agree to the following cancellation policy: If you are unable to be present to your appointment, we ask for a 48 business hours notice, or a $85 fee will be charged.<\/label><input type='hidden' name='input_128.2' value='I have read and agree to the following cancellation policy: If you are unable to be present to your appointment, we ask for a 48 business hours notice, or a $85 fee will be charged.' class='gform_hidden' \/><input type='hidden' name='input_128.3' value='4' 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'>Patient or Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_11_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input type='hidden' class='gform_hidden' name='input_11_2_valid' id='input_11_2_valid' \/><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_en\/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='30 juillet 2026 11h23' 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_125\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#545454;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">RESERVED TO THE ADMINISTRATION<\/div><\/div><div id=\"field_11_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea grisadmin 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_112'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_11_112' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_113\" class=\"gfield gfield--type-textarea gfield--input-type-textarea grisadmin 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_113'>Precautions<\/label><div class='ginput_container 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