{"id":15,"date":"2017-11-06T22:20:28","date_gmt":"2017-11-06T21:20:28","guid":{"rendered":"https:\/\/monorthosurleplateau.ca\/questionnaires\/?page_id=15"},"modified":"2025-07-02T20:10:47","modified_gmt":"2025-07-02T18:10:47","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/monorthosurleplateau.ca\/questionnaires\/medical-questionnaire\/","title":{"rendered":"Medical Questionnaire"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-12\" src=\"https:\/\/monorthosurleplateau.ca\/questionnaires\/wp-content\/uploads\/2017\/05\/logo.jpg\" alt=\"\" width=\"272\" height=\"139\" \/><\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/questionnaires\/wp-json\/wp\/v2\/pages\/15#gf_2' data-formid='2' novalidate>\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<h3 class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_0' style='width:0%; color:#ffffff; background-color:#7991b7;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_150\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">MEDICAL AND DENTAL QUESTIONNAIRE<\/h2><div class='gsection_description' id='gfield_description_2_150'>A dental file is created as part of the care provided: it is protected by law and patient-physician privilege. It is kept in the office and only the orthodontist and their personnel have access to it. The patient also has the right to access and make corrections to the file. <\/div><\/li><li id=\"field_2_1\" class=\"gfield gfield--type-name gf_left_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 gfield_label_before_complex' >Patient information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_1'>\n                            \n                            <span id='input_2_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>Patient first name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Patient last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_2'>\n\t\t\t<li class='gchoice gchoice_2_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='M'  id='choice_2_2_0'    \/>\n\t\t\t\t<label for='choice_2_2_0' id='label_2_2_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='F'  id='choice_2_2_1'    \/>\n\t\t\t\t<label for='choice_2_2_1' id='label_2_2_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_164\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_164'>Referred by<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_2_164' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-address gf_left_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 gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_1_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_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_3_label' class='gform-field-label gform-field-label--type-sub '>Town<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_3_4_container' >\n                                        <select name='input_3.4' id='input_2_3_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_2_3_4' id='input_2_3_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_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_2_3_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_163\" class=\"gfield gfield--type-phone gf_middle_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_2_163'>Home 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_163' id='input_2_163' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-phone gf_right_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_2_5'>Mobile phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_172\" class=\"gfield gfield--type-phone gf_left_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_2_172'>Office phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_172' id='input_2_172' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_173\" class=\"gfield gfield--type-text gf_middle_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_2_173'>Ext.<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_2_173' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-email gf_right_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_2_8'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_2_8' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_9\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have dental insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_9'>\n\t\t\t<li class='gchoice gchoice_2_9_0'>\n\t\t\t\t<input name='input_9' type='radio' value='Yes'  id='choice_2_9_0'    \/>\n\t\t\t\t<label for='choice_2_9_0' id='label_2_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_9_1'>\n\t\t\t\t<input name='input_9' type='radio' value='No'  id='choice_2_9_1'    \/>\n\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline 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' >Appointment confirmations made by<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_142'>\n\t\t\t<li class='gchoice gchoice_2_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Home'  id='choice_2_142_0'    \/>\n\t\t\t\t<label for='choice_2_142_0' id='label_2_142_0' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='Office'  id='choice_2_142_1'    \/>\n\t\t\t\t<label for='choice_2_142_1' id='label_2_142_1' class='gform-field-label gform-field-label--type-inline'>Office<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_142_2'>\n\t\t\t\t<input name='input_142' type='radio' value='Mobile'  id='choice_2_142_2'    \/>\n\t\t\t\t<label for='choice_2_142_2' id='label_2_142_2' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_142_3'>\n\t\t\t\t<input name='input_142' type='radio' value='Email'  id='choice_2_142_3'    \/>\n\t\t\t\t<label for='choice_2_142_3' id='label_2_142_3' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_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_2_12'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_2_12' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_2_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_12_date_format' class='screen-reader-text'>AAAA slash MM slash JJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_12' class='gform_hidden' value='https:\/\/monorthosurleplateau.ca\/questionnaires\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text gf_left_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_2_13'>Health insurance number<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-text gf_left_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_2_19'>Emergency contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_6\" class=\"gfield gfield--type-phone gf_left_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_2_6'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-text gf_middle_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_2_10'>Ext.<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text gf_middle_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_2_16'>Under the age of 14, enter the name of the parent\/guardian<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Indicate<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_18'>\n\t\t\t<li class='gchoice gchoice_2_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Parent'  id='choice_2_18_0'    \/>\n\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Guardian'  id='choice_2_18_1'    \/>\n\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_list_2col gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Reasons for the consultation<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_23'><li class='gchoice gchoice_2_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Lack of space'  id='choice_2_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_1' id='label_2_23_1' class='gform-field-label gform-field-label--type-inline'>Lack of space<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='Aesthetics of the smile'  id='choice_2_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_2' id='label_2_23_2' class='gform-field-label gform-field-label--type-inline'>Aesthetics of the smile<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='Impacted teeth'  id='choice_2_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_3' id='label_2_23_3' class='gform-field-label gform-field-label--type-inline'>Impacted teeth<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.4' type='checkbox'  value='Functional orthodontics'  id='choice_2_23_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_4' id='label_2_23_4' class='gform-field-label gform-field-label--type-inline'>Functional orthodontics<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.5' type='checkbox'  value='Rehabilitation'  id='choice_2_23_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_5' id='label_2_23_5' class='gform-field-label gform-field-label--type-inline'>Rehabilitation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.6' type='checkbox'  value='Invisalign treatment'  id='choice_2_23_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_6' id='label_2_23_6' class='gform-field-label gform-field-label--type-inline'>Invisalign treatment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.7' type='checkbox'  value='Malocclusion'  id='choice_2_23_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_7' id='label_2_23_7' class='gform-field-label gform-field-label--type-inline'>Malocclusion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.8' type='checkbox'  value='Pain'  id='choice_2_23_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_8' id='label_2_23_8' class='gform-field-label gform-field-label--type-inline'>Pain<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_23_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.9' type='checkbox'  value='Other'  id='choice_2_23_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_23_9' id='label_2_23_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-text gf_right_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_2_22'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_151\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">PERSON RESPONSIBLE FOR FEES<\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >PERSON RESPONSIBLE FOR FEES<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_25'><li class='gchoice gchoice_2_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Patient'  id='choice_2_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='Other individual'  id='choice_2_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_2' id='label_2_25_2' class='gform-field-label gform-field-label--type-inline'>Other individual<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-text gf_middle_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_2_27'>Responsible name<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contact information of person responsible for fees<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_26'><li class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='Same as the patient'  id='choice_2_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>Same as the patient<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-address gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_2_28_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_28_1' id='input_2_28_1_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_2_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_2_28_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_28_3' id='input_2_28_3_label' class='gform-field-label gform-field-label--type-sub '>Town<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_28_4_container' >\n                                        <select name='input_28.4' id='input_2_28_4'     aria-required='false'    ><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_2_28_4' id='input_2_28_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_2_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_2_28_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_28_5' id='input_2_28_5_label' class='gform-field-label gform-field-label--type-sub '>Postal code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_2_28_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-phone gf_middle_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_2_29'>Home phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_2_29' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-phone gf_right_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_2_30'>Mobile phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_2_30' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-phone gf_left_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_2_31'>Office phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_2_31' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-text gf_middle_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_2_32'>Ext.<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--type-email gf_right_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_2_33'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_2_33' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_159' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-159' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_156\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">DENTAL HISTORY<\/div><\/li><li id=\"field_2_106\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Last visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_106'>\n\t\t\t<li class='gchoice gchoice_2_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='0 to 6 months'  id='choice_2_106_0'    \/>\n\t\t\t\t<label for='choice_2_106_0' id='label_2_106_0' class='gform-field-label gform-field-label--type-inline'>0 to 6 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='6 to 12 months'  id='choice_2_106_1'    \/>\n\t\t\t\t<label for='choice_2_106_1' id='label_2_106_1' class='gform-field-label gform-field-label--type-inline'>6 to 12 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_106_2'>\n\t\t\t\t<input name='input_106' type='radio' value='12 months or more'  id='choice_2_106_2'    \/>\n\t\t\t\t<label for='choice_2_106_2' id='label_2_106_2' class='gform-field-label gform-field-label--type-inline'>12 months or more<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_107\" class=\"gfield gfield--type-text gf_middle_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_2_107'>Name of current dentist<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_2_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_171\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you authorize us to share observation reports, photos and x-rays with your current dentist<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_171'>\n\t\t\t<li class='gchoice gchoice_2_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='Yes'  id='choice_2_171_0'    \/>\n\t\t\t\t<label for='choice_2_171_0' id='label_2_171_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='No'  id='choice_2_171_1'    \/>\n\t\t\t\t<label for='choice_2_171_1' id='label_2_171_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_157\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">HAVE YOU PREVIOUSLY RECEIVED DENTAL TREATMENTS SUCH AS<\/div><\/li><li id=\"field_2_110\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Dental x-rays<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_110'>\n\t\t\t<li class='gchoice gchoice_2_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='Yes'  id='choice_2_110_0'    \/>\n\t\t\t\t<label for='choice_2_110_0' id='label_2_110_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='No'  id='choice_2_110_1'    \/>\n\t\t\t\t<label for='choice_2_110_1' id='label_2_110_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_147\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Gum treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_147'>\n\t\t\t<li class='gchoice gchoice_2_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Yes'  id='choice_2_147_0'    \/>\n\t\t\t\t<label for='choice_2_147_0' id='label_2_147_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='No'  id='choice_2_147_1'    \/>\n\t\t\t\t<label for='choice_2_147_1' id='label_2_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_111\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter 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' >Orthodontic treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_111'>\n\t\t\t<li class='gchoice gchoice_2_111_0'>\n\t\t\t\t<input name='input_111' type='radio' value='Yes'  id='choice_2_111_0'    \/>\n\t\t\t\t<label for='choice_2_111_0' id='label_2_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_111_1'>\n\t\t\t\t<input name='input_111' type='radio' value='No'  id='choice_2_111_1'    \/>\n\t\t\t\t<label for='choice_2_111_1' id='label_2_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_112\" class=\"gfield gfield--type-text gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_112'>If yes, what is the name of the orthodontist<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_2_112' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_113\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Fillings (repairs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_113'>\n\t\t\t<li class='gchoice gchoice_2_113_0'>\n\t\t\t\t<input name='input_113' type='radio' value='Yes'  id='choice_2_113_0'    \/>\n\t\t\t\t<label for='choice_2_113_0' id='label_2_113_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_113_1'>\n\t\t\t\t<input name='input_113' type='radio' value='No'  id='choice_2_113_1'    \/>\n\t\t\t\t<label for='choice_2_113_1' id='label_2_113_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_114\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Crown(s) and\/or bridge(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_114'>\n\t\t\t<li class='gchoice gchoice_2_114_0'>\n\t\t\t\t<input name='input_114' type='radio' value='Yes'  id='choice_2_114_0'    \/>\n\t\t\t\t<label for='choice_2_114_0' id='label_2_114_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_114_1'>\n\t\t\t\t<input name='input_114' type='radio' value='No'  id='choice_2_114_1'    \/>\n\t\t\t\t<label for='choice_2_114_1' id='label_2_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_115\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter 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' >Root canal treatment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_115'>\n\t\t\t<li class='gchoice gchoice_2_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_2_115_0'    \/>\n\t\t\t\t<label for='choice_2_115_0' id='label_2_115_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='No'  id='choice_2_115_1'    \/>\n\t\t\t\t<label for='choice_2_115_1' id='label_2_115_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_116\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter 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' >Oral surgery treatment or extractions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_116'>\n\t\t\t<li class='gchoice gchoice_2_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='Yes'  id='choice_2_116_0'    \/>\n\t\t\t\t<label for='choice_2_116_0' id='label_2_116_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='No'  id='choice_2_116_1'    \/>\n\t\t\t\t<label for='choice_2_116_1' id='label_2_116_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_117\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Dental implants<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_117'>\n\t\t\t<li class='gchoice gchoice_2_117_0'>\n\t\t\t\t<input name='input_117' type='radio' value='Yes'  id='choice_2_117_0'    \/>\n\t\t\t\t<label for='choice_2_117_0' id='label_2_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_117_1'>\n\t\t\t\t<input name='input_117' type='radio' value='No'  id='choice_2_117_1'    \/>\n\t\t\t\t<label for='choice_2_117_1' id='label_2_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_118\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline 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' >Complete and\/or partial prosthesis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_118'>\n\t\t\t<li class='gchoice gchoice_2_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_2_118_0'    \/>\n\t\t\t\t<label for='choice_2_118_0' id='label_2_118_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='No'  id='choice_2_118_1'    \/>\n\t\t\t\t<label for='choice_2_118_1' id='label_2_118_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_119\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline 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' >Tonsils have been removed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_119'>\n\t\t\t<li class='gchoice gchoice_2_119_0'>\n\t\t\t\t<input name='input_119' type='radio' value='Yes'  id='choice_2_119_0'    \/>\n\t\t\t\t<label for='choice_2_119_0' id='label_2_119_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_119_1'>\n\t\t\t\t<input name='input_119' type='radio' value='No'  id='choice_2_119_1'    \/>\n\t\t\t\t<label for='choice_2_119_1' id='label_2_119_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_120\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline 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' >Do you experience jaw clicking or popping<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_120'>\n\t\t\t<li class='gchoice gchoice_2_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='Yes'  id='choice_2_120_0'    \/>\n\t\t\t\t<label for='choice_2_120_0' id='label_2_120_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='No'  id='choice_2_120_1'    \/>\n\t\t\t\t<label for='choice_2_120_1' id='label_2_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_121\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a deviated nasal septum<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_121'>\n\t\t\t<li class='gchoice gchoice_2_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Yes'  id='choice_2_121_0'    \/>\n\t\t\t\t<label for='choice_2_121_0' id='label_2_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='No'  id='choice_2_121_1'    \/>\n\t\t\t\t<label for='choice_2_121_1' id='label_2_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_122\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline 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' >Do you have difficulty breathing through your nose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_122'>\n\t\t\t<li class='gchoice gchoice_2_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_2_122_0'    \/>\n\t\t\t\t<label for='choice_2_122_0' id='label_2_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_2_122_1'    \/>\n\t\t\t\t<label for='choice_2_122_1' id='label_2_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_123\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline 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' >Have you suffered an injury to the head or face<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_123'>\n\t\t\t<li class='gchoice gchoice_2_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Yes'  id='choice_2_123_0'    \/>\n\t\t\t\t<label for='choice_2_123_0' id='label_2_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='No'  id='choice_2_123_1'    \/>\n\t\t\t\t<label for='choice_2_123_1' id='label_2_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_158\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">ORAL HABITS<\/div><\/li><li id=\"field_2_124\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline 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' >Sucking the fingers<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_124'>\n\t\t\t<li class='gchoice gchoice_2_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_2_124_0'    \/>\n\t\t\t\t<label for='choice_2_124_0' id='label_2_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_2_124_1'    \/>\n\t\t\t\t<label for='choice_2_124_1' id='label_2_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_126\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline 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' >Tongue thrusting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_126'>\n\t\t\t<li class='gchoice gchoice_2_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_2_126_0'    \/>\n\t\t\t\t<label for='choice_2_126_0' id='label_2_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_2_126_1'    \/>\n\t\t\t\t<label for='choice_2_126_1' id='label_2_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_127\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline 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' >Mouth breathing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_127'>\n\t\t\t<li class='gchoice gchoice_2_127_0'>\n\t\t\t\t<input name='input_127' type='radio' value='Yes'  id='choice_2_127_0'    \/>\n\t\t\t\t<label for='choice_2_127_0' id='label_2_127_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_127_1'>\n\t\t\t\t<input name='input_127' type='radio' value='No'  id='choice_2_127_1'    \/>\n\t\t\t\t<label for='choice_2_127_1' id='label_2_127_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_128\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline 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' >Speech problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_128'>\n\t\t\t<li class='gchoice gchoice_2_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='Yes'  id='choice_2_128_0'    \/>\n\t\t\t\t<label for='choice_2_128_0' id='label_2_128_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_2_128_1'    \/>\n\t\t\t\t<label for='choice_2_128_1' id='label_2_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_129\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline 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' >Biting the lips<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_129'>\n\t\t\t<li class='gchoice gchoice_2_129_0'>\n\t\t\t\t<input name='input_129' type='radio' value='Yes'  id='choice_2_129_0'    \/>\n\t\t\t\t<label for='choice_2_129_0' id='label_2_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_129_1'>\n\t\t\t\t<input name='input_129' type='radio' value='No'  id='choice_2_129_1'    \/>\n\t\t\t\t<label for='choice_2_129_1' id='label_2_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_130\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline 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' >Chewing the fingernails<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_130'>\n\t\t\t<li class='gchoice gchoice_2_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='Yes'  id='choice_2_130_0'    \/>\n\t\t\t\t<label for='choice_2_130_0' id='label_2_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='No'  id='choice_2_130_1'    \/>\n\t\t\t\t<label for='choice_2_130_1' id='label_2_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_131\" class=\"gfield gfield--type-radio gfield--type-choice gf_third_quarter gf_list_inline 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' >Clenching the teeth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_131'>\n\t\t\t<li class='gchoice gchoice_2_131_0'>\n\t\t\t\t<input name='input_131' type='radio' value='Yes'  id='choice_2_131_0'    \/>\n\t\t\t\t<label for='choice_2_131_0' id='label_2_131_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_131_1'>\n\t\t\t\t<input name='input_131' type='radio' value='No'  id='choice_2_131_1'    \/>\n\t\t\t\t<label for='choice_2_131_1' id='label_2_131_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_132\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline 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' >Grinding the teeth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_132'>\n\t\t\t<li class='gchoice gchoice_2_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_2_132_0'    \/>\n\t\t\t\t<label for='choice_2_132_0' id='label_2_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_2_132_1'    \/>\n\t\t\t\t<label for='choice_2_132_1' id='label_2_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_133\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline 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' >Bleeding gums<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_133'>\n\t\t\t<li class='gchoice gchoice_2_133_0'>\n\t\t\t\t<input name='input_133' type='radio' value='Yes'  id='choice_2_133_0'    \/>\n\t\t\t\t<label for='choice_2_133_0' id='label_2_133_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_133_1'>\n\t\t\t\t<input name='input_133' type='radio' value='No'  id='choice_2_133_1'    \/>\n\t\t\t\t<label for='choice_2_133_1' id='label_2_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_134\" class=\"gfield gfield--type-radio gfield--type-choice gf_second_quarter gf_list_inline 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' >Difficulty opening the mouth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_134'>\n\t\t\t<li class='gchoice gchoice_2_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Yes'  id='choice_2_134_0'    \/>\n\t\t\t\t<label for='choice_2_134_0' id='label_2_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_2_134_1'    \/>\n\t\t\t\t<label for='choice_2_134_1' id='label_2_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_149\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline 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' >Frequent headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_149'>\n\t\t\t<li class='gchoice gchoice_2_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Yes'  id='choice_2_149_0'    \/>\n\t\t\t\t<label for='choice_2_149_0' id='label_2_149_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='No'  id='choice_2_149_1'    \/>\n\t\t\t\t<label for='choice_2_149_1' id='label_2_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_135\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline 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' >Do you snore<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_135'>\n\t\t\t<li class='gchoice gchoice_2_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Yes'  id='choice_2_135_0'    \/>\n\t\t\t\t<label for='choice_2_135_0' id='label_2_135_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='No'  id='choice_2_135_1'    \/>\n\t\t\t\t<label for='choice_2_135_1' id='label_2_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_174\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline 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' >Do you have or think you have sleep apnea<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_174'>\n\t\t\t<li class='gchoice gchoice_2_174_0'>\n\t\t\t\t<input name='input_174' type='radio' value='Yes'  id='choice_2_174_0'    \/>\n\t\t\t\t<label for='choice_2_174_0' id='label_2_174_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_174_1'>\n\t\t\t\t<input name='input_174' type='radio' value='No'  id='choice_2_174_1'    \/>\n\t\t\t\t<label for='choice_2_174_1' id='label_2_174_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_137\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_137'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_2_137' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_136\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Do you play a musical instrument<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_136'>\n\t\t\t<li class='gchoice gchoice_2_136_0'>\n\t\t\t\t<input name='input_136' type='radio' value='Yes'  id='choice_2_136_0'    \/>\n\t\t\t\t<label for='choice_2_136_0' id='label_2_136_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_136_1'>\n\t\t\t\t<input name='input_136' type='radio' value='No'  id='choice_2_136_1'    \/>\n\t\t\t\t<label for='choice_2_136_1' id='label_2_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_175\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_175'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_2_175' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_161' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_161' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-161' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_152\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">MEDICAL HISTORY<\/div><\/li><li id=\"field_2_39\" class=\"gfield gfield--type-radio gfield--type-choice gf_first_quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you currently being treated by a physician<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_39'>\n\t\t\t<li class='gchoice gchoice_2_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_2_39_0'    \/>\n\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_2_39_1'    \/>\n\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_35\" class=\"gfield gfield--type-text gf_second_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_35'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_2_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_36\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'>Physician name<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_40\" class=\"gfield gfield--type-phone gf_fourth_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>Physician telephone<\/label><div class='ginput_container ginput_container_phone'><input name='input_40' id='input_2_40' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Are you currently being treated by a therapist, psychotherapist, osteopath, posture specialist, physiotherapist or other professional<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_41'>\n\t\t\t<li class='gchoice gchoice_2_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_2_41_0'    \/>\n\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_2_41_1'    \/>\n\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_42\" class=\"gfield gfield--type-text gf_middle_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_2_42'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_2_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--type-text gf_right_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_2_43'>Indicate all medication (including contraceptives and hormones) being taken now or during the last 12 months<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_44\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Do you take natural or homeopathic products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_44'>\n\t\t\t<li class='gchoice gchoice_2_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Yes'  id='choice_2_44_0'    \/>\n\t\t\t\t<label for='choice_2_44_0' id='label_2_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='No'  id='choice_2_44_1'    \/>\n\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-text gf_middle_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_2_45'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Have you recently had a significant change in body weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_46'>\n\t\t\t<li class='gchoice gchoice_2_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Yes'  id='choice_2_46_0'    \/>\n\t\t\t\t<label for='choice_2_46_0' id='label_2_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='No'  id='choice_2_46_1'    \/>\n\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Are you pregnant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_47'>\n\t\t\t<li class='gchoice gchoice_2_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_2_47_0'    \/>\n\t\t\t\t<label for='choice_2_47_0' id='label_2_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_2_47_1'    \/>\n\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_47_2'>\n\t\t\t\t<input name='input_47' type='radio' value='Not applicable'  id='choice_2_47_2'    \/>\n\t\t\t\t<label for='choice_2_47_2' id='label_2_47_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Are you breastfeeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_48'>\n\t\t\t<li class='gchoice gchoice_2_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_2_48_0'    \/>\n\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_2_48_1'    \/>\n\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_48_2'>\n\t\t\t\t<input name='input_48' type='radio' value='Not applicable'  id='choice_2_48_2'    \/>\n\t\t\t\t<label for='choice_2_48_2' id='label_2_48_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_153\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">HAVE YOU HAD OR DO YOU CURRENTLY SUFFER FROM<\/div><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Heart attack<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_51'>\n\t\t\t<li class='gchoice gchoice_2_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Yes'  id='choice_2_51_0'    \/>\n\t\t\t\t<label for='choice_2_51_0' id='label_2_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='No'  id='choice_2_51_1'    \/>\n\t\t\t\t<label for='choice_2_51_1' id='label_2_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_53\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Angina<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_53'>\n\t\t\t<li class='gchoice gchoice_2_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_2_53_0'    \/>\n\t\t\t\t<label for='choice_2_53_0' id='label_2_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_2_53_1'    \/>\n\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_165\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Infective endocarditis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_165'>\n\t\t\t<li class='gchoice gchoice_2_165_0'>\n\t\t\t\t<input name='input_165' type='radio' value='Yes'  id='choice_2_165_0'    \/>\n\t\t\t\t<label for='choice_2_165_0' id='label_2_165_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_165_1'>\n\t\t\t\t<input name='input_165' type='radio' value='No'  id='choice_2_165_1'    \/>\n\t\t\t\t<label for='choice_2_165_1' id='label_2_165_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_50\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Surgery to place and repair a valve<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_50'>\n\t\t\t<li class='gchoice gchoice_2_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_2_50_0'    \/>\n\t\t\t\t<label for='choice_2_50_0' id='label_2_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_2_50_1'    \/>\n\t\t\t\t<label for='choice_2_50_1' id='label_2_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Hemophilia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_57'>\n\t\t\t<li class='gchoice gchoice_2_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes'  id='choice_2_57_0'    \/>\n\t\t\t\t<label for='choice_2_57_0' id='label_2_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_2_57_1'    \/>\n\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_143\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Prolonged bleeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_143'>\n\t\t\t<li class='gchoice gchoice_2_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_2_143_0'    \/>\n\t\t\t\t<label for='choice_2_143_0' id='label_2_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_2_143_1'    \/>\n\t\t\t\t<label for='choice_2_143_1' id='label_2_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_59\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Anemia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'>\n\t\t\t<li class='gchoice gchoice_2_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_2_59_0'    \/>\n\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_2_59_1'    \/>\n\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_166\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >High blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_166'>\n\t\t\t<li class='gchoice gchoice_2_166_0'>\n\t\t\t\t<input name='input_166' type='radio' value='Yes'  id='choice_2_166_0'    \/>\n\t\t\t\t<label for='choice_2_166_0' id='label_2_166_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_166_1'>\n\t\t\t\t<input name='input_166' type='radio' value='No'  id='choice_2_166_1'    \/>\n\t\t\t\t<label for='choice_2_166_1' id='label_2_166_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_167\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Low blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_167'>\n\t\t\t<li class='gchoice gchoice_2_167_0'>\n\t\t\t\t<input name='input_167' type='radio' value='Yes'  id='choice_2_167_0'    \/>\n\t\t\t\t<label for='choice_2_167_0' id='label_2_167_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_167_1'>\n\t\t\t\t<input name='input_167' type='radio' value='No'  id='choice_2_167_1'    \/>\n\t\t\t\t<label for='choice_2_167_1' id='label_2_167_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Other blood-related problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_60'>\n\t\t\t<li class='gchoice gchoice_2_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Yes'  id='choice_2_60_0'    \/>\n\t\t\t\t<label for='choice_2_60_0' id='label_2_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='No'  id='choice_2_60_1'    \/>\n\t\t\t\t<label for='choice_2_60_1' id='label_2_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_61\" class=\"gfield gfield--type-text gf_middle_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_2_61'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_2_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_154\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">OTHER HEALTH INFORMATION<\/div><\/li><li id=\"field_2_63\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Frequent colds or sinusitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'>\n\t\t\t<li class='gchoice gchoice_2_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_2_63_0'    \/>\n\t\t\t\t<label for='choice_2_63_0' id='label_2_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_2_63_1'    \/>\n\t\t\t\t<label for='choice_2_63_1' id='label_2_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_64\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Tuberculosis or lung problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_64'>\n\t\t\t<li class='gchoice gchoice_2_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_2_64_0'    \/>\n\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_2_64_1'    \/>\n\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_65\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Digestive problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_65'>\n\t\t\t<li class='gchoice gchoice_2_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_2_65_0'    \/>\n\t\t\t\t<label for='choice_2_65_0' id='label_2_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_2_65_1'    \/>\n\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_66\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Stomach ulcer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_66'>\n\t\t\t<li class='gchoice gchoice_2_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes'  id='choice_2_66_0'    \/>\n\t\t\t\t<label for='choice_2_66_0' id='label_2_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_2_66_1'    \/>\n\t\t\t\t<label for='choice_2_66_1' id='label_2_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_67\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Liver problems (Hepatitis A, B or C, cirrhosis)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_67'>\n\t\t\t<li class='gchoice gchoice_2_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Yes'  id='choice_2_67_0'    \/>\n\t\t\t\t<label for='choice_2_67_0' id='label_2_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='No'  id='choice_2_67_1'    \/>\n\t\t\t\t<label for='choice_2_67_1' id='label_2_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_68\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Kidney problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_68'>\n\t\t\t<li class='gchoice gchoice_2_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_2_68_0'    \/>\n\t\t\t\t<label for='choice_2_68_0' id='label_2_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_2_68_1'    \/>\n\t\t\t\t<label for='choice_2_68_1' id='label_2_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_145\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_145'>\n\t\t\t<li class='gchoice gchoice_2_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Yes'  id='choice_2_145_0'    \/>\n\t\t\t\t<label for='choice_2_145_0' id='label_2_145_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='No'  id='choice_2_145_1'    \/>\n\t\t\t\t<label for='choice_2_145_1' id='label_2_145_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_70\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Thyroid problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_70'>\n\t\t\t<li class='gchoice gchoice_2_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_2_70_0'    \/>\n\t\t\t\t<label for='choice_2_70_0' id='label_2_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_2_70_1'    \/>\n\t\t\t\t<label for='choice_2_70_1' id='label_2_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_69\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Skin condition<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_69'>\n\t\t\t<li class='gchoice gchoice_2_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_2_69_0'    \/>\n\t\t\t\t<label for='choice_2_69_0' id='label_2_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_2_69_1'    \/>\n\t\t\t\t<label for='choice_2_69_1' id='label_2_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_71\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Vision problems (eyes)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_71'>\n\t\t\t<li class='gchoice gchoice_2_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Yes'  id='choice_2_71_0'    \/>\n\t\t\t\t<label for='choice_2_71_0' id='label_2_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='No'  id='choice_2_71_1'    \/>\n\t\t\t\t<label for='choice_2_71_1' id='label_2_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_74\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Do you take bisphosphonates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_74'>\n\t\t\t<li class='gchoice gchoice_2_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_2_74_0'    \/>\n\t\t\t\t<label for='choice_2_74_0' id='label_2_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_2_74_1'    \/>\n\t\t\t\t<label for='choice_2_74_1' id='label_2_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_75\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Do you have a joint prosthesis (hip, knee, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_75'>\n\t\t\t<li class='gchoice gchoice_2_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_2_75_0'    \/>\n\t\t\t\t<label for='choice_2_75_0' id='label_2_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='No'  id='choice_2_75_1'    \/>\n\t\t\t\t<label for='choice_2_75_1' id='label_2_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_72\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Osteoporosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_72'>\n\t\t\t<li class='gchoice gchoice_2_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_2_72_0'    \/>\n\t\t\t\t<label for='choice_2_72_0' id='label_2_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_2_72_1'    \/>\n\t\t\t\t<label for='choice_2_72_1' id='label_2_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_73\" class=\"gfield gfield--type-text gf_middle_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_2_73'>If yes, prevention\/treatments<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_146\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Epilepsy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_146'>\n\t\t\t<li class='gchoice gchoice_2_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='Yes'  id='choice_2_146_0'    \/>\n\t\t\t\t<label for='choice_2_146_0' id='label_2_146_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='No'  id='choice_2_146_1'    \/>\n\t\t\t\t<label for='choice_2_146_1' id='label_2_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_76\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Problems or diseases of the nervous system<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_76'>\n\t\t\t<li class='gchoice gchoice_2_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Yes'  id='choice_2_76_0'    \/>\n\t\t\t\t<label for='choice_2_76_0' id='label_2_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='No'  id='choice_2_76_1'    \/>\n\t\t\t\t<label for='choice_2_76_1' id='label_2_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_77\" class=\"gfield gfield--type-text gf_right_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_2_77'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_2_77' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_78\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Psychological or emotional condition<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_78'>\n\t\t\t<li class='gchoice gchoice_2_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_2_78_0'    \/>\n\t\t\t\t<label for='choice_2_78_0' id='label_2_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_2_78_1'    \/>\n\t\t\t\t<label for='choice_2_78_1' id='label_2_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_169\" class=\"gfield gfield--type-text gf_right_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_2_169'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_2_169' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_168\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Have you been diagnosed with autism, ADD or other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_168'>\n\t\t\t<li class='gchoice gchoice_2_168_0'>\n\t\t\t\t<input name='input_168' type='radio' value='Yes'  id='choice_2_168_0'    \/>\n\t\t\t\t<label for='choice_2_168_0' id='label_2_168_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_168_1'>\n\t\t\t\t<input name='input_168' type='radio' value='No'  id='choice_2_168_1'    \/>\n\t\t\t\t<label for='choice_2_168_1' id='label_2_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_79\" class=\"gfield gfield--type-text gf_right_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_2_79'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_2_79' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_80\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Dizziness, loss of consciousness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_80'>\n\t\t\t<li class='gchoice gchoice_2_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_2_80_0'    \/>\n\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_2_80_1'    \/>\n\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_81\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Earaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_81'>\n\t\t\t<li class='gchoice gchoice_2_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Yes'  id='choice_2_81_0'    \/>\n\t\t\t\t<label for='choice_2_81_0' id='label_2_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_2_81_1'    \/>\n\t\t\t\t<label for='choice_2_81_1' id='label_2_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_82\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Hay fever<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_82'>\n\t\t\t<li class='gchoice gchoice_2_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_2_82_0'    \/>\n\t\t\t\t<label for='choice_2_82_0' id='label_2_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='No'  id='choice_2_82_1'    \/>\n\t\t\t\t<label for='choice_2_82_1' id='label_2_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_83\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_83'>\n\t\t\t<li class='gchoice gchoice_2_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Yes'  id='choice_2_83_0'    \/>\n\t\t\t\t<label for='choice_2_83_0' id='label_2_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='No'  id='choice_2_83_1'    \/>\n\t\t\t\t<label for='choice_2_83_1' id='label_2_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_84\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Do you smoke<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_84'>\n\t\t\t<li class='gchoice gchoice_2_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes'  id='choice_2_84_0'    \/>\n\t\t\t\t<label for='choice_2_84_0' id='label_2_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='No'  id='choice_2_84_1'    \/>\n\t\t\t\t<label for='choice_2_84_1' id='label_2_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='On occasion'  id='choice_2_84_2'    \/>\n\t\t\t\t<label for='choice_2_84_2' id='label_2_84_2' class='gform-field-label gform-field-label--type-inline'>On occasion<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_101\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter 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' >Do you use drugs<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_101'>\n\t\t\t<li class='gchoice gchoice_2_101_0'>\n\t\t\t\t<input name='input_101' type='radio' value='Yes'  id='choice_2_101_0'    \/>\n\t\t\t\t<label for='choice_2_101_0' id='label_2_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_101_1'>\n\t\t\t\t<input name='input_101' type='radio' value='No'  id='choice_2_101_1'    \/>\n\t\t\t\t<label for='choice_2_101_1' id='label_2_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_102\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Do you drink alcohol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_102'>\n\t\t\t<li class='gchoice gchoice_2_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='Little or none'  id='choice_2_102_0'    \/>\n\t\t\t\t<label for='choice_2_102_0' id='label_2_102_0' class='gform-field-label gform-field-label--type-inline'>Little or none<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='Moderately'  id='choice_2_102_1'    \/>\n\t\t\t\t<label for='choice_2_102_1' id='label_2_102_1' class='gform-field-label gform-field-label--type-inline'>Moderately<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_102_2'>\n\t\t\t\t<input name='input_102' type='radio' value='Heavily'  id='choice_2_102_2'    \/>\n\t\t\t\t<label for='choice_2_102_2' id='label_2_102_2' class='gform-field-label gform-field-label--type-inline'>Heavily<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_103\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Have you ever been hospitalized or have undergone any surgery other than dental?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_103'>\n\t\t\t<li class='gchoice gchoice_2_103_0'>\n\t\t\t\t<input name='input_103' type='radio' value='Yes'  id='choice_2_103_0'    \/>\n\t\t\t\t<label for='choice_2_103_0' id='label_2_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_103_1'>\n\t\t\t\t<input name='input_103' type='radio' value='No'  id='choice_2_103_1'    \/>\n\t\t\t\t<label for='choice_2_103_1' id='label_2_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_104\" class=\"gfield gfield--type-text gf_right_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_2_104'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_2_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_85\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Have you received radiation therapy and\/or chemotherapy (tumour)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_85'>\n\t\t\t<li class='gchoice gchoice_2_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_2_85_0'    \/>\n\t\t\t\t<label for='choice_2_85_0' id='label_2_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_2_85_1'    \/>\n\t\t\t\t<label for='choice_2_85_1' id='label_2_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_86\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_right_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' >Sexually transmitted infection (STI)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_86'>\n\t\t\t<li class='gchoice gchoice_2_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='Yes'  id='choice_2_86_0'    \/>\n\t\t\t\t<label for='choice_2_86_0' id='label_2_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='No'  id='choice_2_86_1'    \/>\n\t\t\t\t<label for='choice_2_86_1' id='label_2_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_87\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_left_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' >Living with the HIV virus (HIV-positive)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_87'>\n\t\t\t<li class='gchoice gchoice_2_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_2_87_0'    \/>\n\t\t\t\t<label for='choice_2_87_0' id='label_2_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_2_87_1'    \/>\n\t\t\t\t<label for='choice_2_87_1' id='label_2_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_160' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_160' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-160' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_155\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><div style=\"background-color:#bdc7d1;font-size:16px;padding:5px;\">HAVE YOU EXPERIENCED AN ALLERGIC OR OTHER TYPE OF REACTION TO THE FOLLOWING PRODUCTS<\/div><\/li><li id=\"field_2_90\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Latex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_90'>\n\t\t\t<li class='gchoice gchoice_2_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_2_90_0'    \/>\n\t\t\t\t<label for='choice_2_90_0' id='label_2_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='No'  id='choice_2_90_1'    \/>\n\t\t\t\t<label for='choice_2_90_1' id='label_2_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_91\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Foods<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_91'>\n\t\t\t<li class='gchoice gchoice_2_91_0'>\n\t\t\t\t<input name='input_91' type='radio' value='Yes'  id='choice_2_91_0'    \/>\n\t\t\t\t<label for='choice_2_91_0' id='label_2_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_91_1'>\n\t\t\t\t<input name='input_91' type='radio' value='No'  id='choice_2_91_1'    \/>\n\t\t\t\t<label for='choice_2_91_1' id='label_2_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_92\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter 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' >Iodine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_92'>\n\t\t\t<li class='gchoice gchoice_2_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_2_92_0'    \/>\n\t\t\t\t<label for='choice_2_92_0' id='label_2_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='No'  id='choice_2_92_1'    \/>\n\t\t\t\t<label for='choice_2_92_1' id='label_2_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_93\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter 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' >Aspirine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_93'>\n\t\t\t<li class='gchoice gchoice_2_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_2_93_0'    \/>\n\t\t\t\t<label for='choice_2_93_0' id='label_2_93_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_2_93_1'    \/>\n\t\t\t\t<label for='choice_2_93_1' id='label_2_93_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_94\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Sulfonamides (sulfa drugs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_94'>\n\t\t\t<li class='gchoice gchoice_2_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Yes'  id='choice_2_94_0'    \/>\n\t\t\t\t<label for='choice_2_94_0' id='label_2_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='No'  id='choice_2_94_1'    \/>\n\t\t\t\t<label for='choice_2_94_1' id='label_2_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_95\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Penicillin<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_95'>\n\t\t\t<li class='gchoice gchoice_2_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Yes'  id='choice_2_95_0'    \/>\n\t\t\t\t<label for='choice_2_95_0' id='label_2_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='No'  id='choice_2_95_1'    \/>\n\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_96\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_third_quarter 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' >Codeine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_96'>\n\t\t\t<li class='gchoice gchoice_2_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Yes'  id='choice_2_96_0'    \/>\n\t\t\t\t<label for='choice_2_96_0' id='label_2_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='No'  id='choice_2_96_1'    \/>\n\t\t\t\t<label for='choice_2_96_1' id='label_2_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_97\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_fourth_quarter 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' >Other antibiotics<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_97'>\n\t\t\t<li class='gchoice gchoice_2_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Yes'  id='choice_2_97_0'    \/>\n\t\t\t\t<label for='choice_2_97_0' id='label_2_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='No'  id='choice_2_97_1'    \/>\n\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_98\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_first_quarter 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' >Local anesthetic<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_98'>\n\t\t\t<li class='gchoice gchoice_2_98_0'>\n\t\t\t\t<input name='input_98' type='radio' value='Yes'  id='choice_2_98_0'    \/>\n\t\t\t\t<label for='choice_2_98_0' id='label_2_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_98_1'>\n\t\t\t\t<input name='input_98' type='radio' value='No'  id='choice_2_98_1'    \/>\n\t\t\t\t<label for='choice_2_98_1' id='label_2_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_99\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_second_quarter 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' >Other allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_99'>\n\t\t\t<li class='gchoice gchoice_2_99_0'>\n\t\t\t\t<input name='input_99' type='radio' value='Yes'  id='choice_2_99_0'    \/>\n\t\t\t\t<label for='choice_2_99_0' id='label_2_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_99_1'>\n\t\t\t\t<input name='input_99' type='radio' value='No'  id='choice_2_99_1'    \/>\n\t\t\t\t<label for='choice_2_99_1' id='label_2_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_100\" class=\"gfield gfield--type-text gf_third_quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_100'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_2_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_162' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_2_162' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_5' class='gform_page' data-js='page-field-id-162' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_2_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_138\" class=\"gfield gfield--type-radio gfield--type-choice gf_fourth_quarter gf_list_inline 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' >Is your child in a period of active growth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_138'>\n\t\t\t<li class='gchoice gchoice_2_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='Yes'  id='choice_2_138_0'    \/>\n\t\t\t\t<label for='choice_2_138_0' id='label_2_138_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='No'  id='choice_2_138_1'    \/>\n\t\t\t\t<label for='choice_2_138_1' id='label_2_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_138_2'>\n\t\t\t\t<input name='input_138' type='radio' value='Non applicable'  id='choice_2_138_2'    \/>\n\t\t\t\t<label for='choice_2_138_2' id='label_2_138_2' class='gform-field-label gform-field-label--type-inline'>Non applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_139\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Does your child seem to have reached puberty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_139'>\n\t\t\t<li class='gchoice gchoice_2_139_0'>\n\t\t\t\t<input name='input_139' type='radio' value='Yes'  id='choice_2_139_0'    \/>\n\t\t\t\t<label for='choice_2_139_0' id='label_2_139_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_139_1'>\n\t\t\t\t<input name='input_139' type='radio' value='No'  id='choice_2_139_1'    \/>\n\t\t\t\t<label for='choice_2_139_1' id='label_2_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_139_2'>\n\t\t\t\t<input name='input_139' type='radio' value='Not applicable'  id='choice_2_139_2'    \/>\n\t\t\t\t<label for='choice_2_139_2' id='label_2_139_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_140\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gf_middle_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' >Has menstruation begun<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_140'>\n\t\t\t<li class='gchoice gchoice_2_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_2_140_0'    \/>\n\t\t\t\t<label for='choice_2_140_0' id='label_2_140_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_2_140_1'    \/>\n\t\t\t\t<label for='choice_2_140_1' id='label_2_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_140_2'>\n\t\t\t\t<input name='input_140' type='radio' value='Not applicable'  id='choice_2_140_2'    \/>\n\t\t\t\t<label for='choice_2_140_2' id='label_2_140_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_141\" class=\"gfield gfield--type-text gf_right_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_2_141'>If yes, beginning when<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_2_141' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_177\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label 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><\/label><div class='ginput_container ginput_container_consent'><input name='input_177.1' id='input_2_177_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_177\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_177_1' >I hereby give my consent to the collection, use and disclosure of my personal information by MON ORTHO SUR LE PLATEAU for the purpose of providing dental services.<\/label><input type='hidden' name='input_177.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by MON ORTHO SUR LE PLATEAU for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_177.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_177' tabindex='0'>More information about our <a href=\"https:\/\/monorthosurleplateau.ca\/en_politiqueconfidentialite.html\" target=\"_blank\" rel=\"noopener noreferrer\">Cookie Policy<\/a><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_2' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit your informations'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input 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