{"id":45656,"date":"2022-06-07T12:45:21","date_gmt":"2022-06-07T12:45:21","guid":{"rendered":"https:\/\/www.drhorvath.de\/?page_id=45656"},"modified":"2023-11-14T15:34:00","modified_gmt":"2023-11-14T15:34:00","slug":"medical-history","status":"publish","type":"page","link":"https:\/\/www.drhorvath.de\/en\/welcome\/medical-history\/","title":{"rendered":"Medical history"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"45656\" class=\"elementor elementor-45656 elementor-45615\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-65324dfa formSection elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"65324dfa\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7d047218\" data-id=\"7d047218\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-52bed049 sectionCustomTitleBlock elementor-widget elementor-widget-heading\" data-id=\"52bed049\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Medical History<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3b188918 elementor-widget elementor-widget-text-editor\" data-id=\"3b188918\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tWelcome to our clinic. It\u2019s great you\u2019re here! Your medical history helps us in the preparation of your treatment. Without information on your health, we cannot perform any dental treatments. Please complete the questionnaire as thoroughly as possible. Information highlighted with a star (*) are voluntary. Please also note our information on data processing. Please ask our staff if you have any questions.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3d2158d customFormStyle elementor-widget elementor-widget-shortcode\" data-id=\"3d2158d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_7' style='display:none'><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7'  action='\/en\/wp-json\/wp\/v2\/pages\/45656' data-formid='7' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdF33QqAAAAALdcTEKogNu_Fis_mOm5ZUUTAezT' data-tabindex='0'><input id=\"input_cd9dd5320020fefeee61b975273695e9\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_cd9dd5320020fefeee61b975273695e9\" value=\"\"\/><\/div><div id='gf_page_steps_7' class='gf_page_steps'><div id='gf_step_7_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Step 1\/4<\/span><\/div><div id='gf_step_7_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Step 2\/4<\/span><\/div><div id='gf_step_7_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Step 3\/4<\/span><\/div><div id='gf_step_7_4' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Step 4\/4<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_1\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Personal information<\/h3><\/div><div id=\"field_7_36\" class=\"gfield gfield--type-html gfield--width-full error-validation-block gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >There is a problem with the input. Please check the fields.<\/div><div id=\"field_7_4\" class=\"gfield gfield--type-text gfield--width-full 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_7_4'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_7_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"First name(Required)\"><\/div><\/div><div id=\"field_7_5\" class=\"gfield gfield--type-text gfield--width-full 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_7_5'>Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_7_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Last name(Required)\"><\/div><\/div><div id=\"field_7_7\" class=\"gfield gfield--type-text gfield--width-full 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_7_7'>Family doctor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_7_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Family doctor(Required)\"><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_2' 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_7_2' class='gform_page' data-js='page-field-id-2' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_8\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical history<\/h3><\/div><div id=\"field_7_38\" class=\"gfield gfield--type-html gfield--width-full error-validation-block gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >There is a problem with the input. Please check the fields.<\/div><fieldset id=\"field_7_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you recently been ill, under medical care or in the hospital? If so, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_9'>\n\t\t\t<div class='gchoice gchoice_7_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_7_9_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_9_0' id='label_7_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_7_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_9_1' id='label_7_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_10\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_10'>If so, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_7_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"If so, why?(Required)\"><\/div><\/div><fieldset id=\"field_7_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had a serious disease or surgery? If so, which?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_11'>\n\t\t\t<div class='gchoice gchoice_7_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Yes'  id='choice_7_11_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_11_0' id='label_7_11_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='No'  id='choice_7_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_11_1' id='label_7_11_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_12'>Illness or Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_7_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Illness or Surgery(Required)\"><\/div><\/div><fieldset id=\"field_7_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you take any medications? If so, which?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_13'>\n\t\t\t<div class='gchoice gchoice_7_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Yes'  id='choice_7_13_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_13_0' id='label_7_13_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='No'  id='choice_7_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_13_1' id='label_7_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_14\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_14'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_7_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Medication(Required)\"><\/div><\/div><fieldset id=\"field_7_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you take or have you ever taken bisphosphonates (e.g. due to osteoporosis, tumor)? If yes, how often and why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_15'>\n\t\t\t<div class='gchoice gchoice_7_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Yes'  id='choice_7_15_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_15_0' id='label_7_15_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='No'  id='choice_7_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_15_1' id='label_7_15_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_16\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_16'>Bisphosphonates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_7_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Bisphosphonates(Required)\"><\/div><\/div><fieldset id=\"field_7_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a current or former smoker? If so, how much?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_17'>\n\t\t\t<div class='gchoice gchoice_7_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_7_17_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_17_0' id='label_7_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_7_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_17_1' id='label_7_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_18'>Do you smoke<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_7_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Do you smoke(Required)\"><\/div><\/div><fieldset id=\"field_7_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had an uncommon reaction to an injection or medication? If so, which?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_19'>\n\t\t\t<div class='gchoice gchoice_7_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_7_19_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_19_0' id='label_7_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_7_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_19_1' id='label_7_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_20\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_20'>Reaction to Injections<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_7_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Reaction to Injections(Required)\"><\/div><\/div><fieldset id=\"field_7_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have a prolonged bleeding time? If so, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_21'>\n\t\t\t<div class='gchoice gchoice_7_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_7_21_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_21_0' id='label_7_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_7_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_1' id='label_7_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_22\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_22'>Bleed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_7_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Bleed(Required)\"><\/div><\/div><fieldset id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have problems breathing or sleeping? If so, why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_23'>\n\t\t\t<div class='gchoice gchoice_7_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_7_23_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_23_0' id='label_7_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_7_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_24\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_24'>Trouble breathing or sleeping<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_7_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Trouble breathing or sleeping(Required)\"><\/div><\/div><fieldset id=\"field_7_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Woman: Are you pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_25'>\n\t\t\t<div class='gchoice gchoice_7_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_7_25_0' onchange='gformToggleRadioOther( this )'    \/ aria-label=\"Yes\">\n\t\t\t\t\t<label for='choice_7_25_0' id='label_7_25_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_7_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_25_1' id='label_7_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_26' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Back'  \/> <input type='button' id='gform_next_button_7_26' 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_7_3' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Do you have or have you ever had one of the following diseases?<\/h3><\/div><div id=\"field_7_39\" class=\"gfield gfield--type-html gfield--width-full error-validation-block gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >There is a problem with the input. Please check the fields.<\/div><fieldset id=\"field_7_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_28'><div class='gchoice gchoice_7_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Allergies. Do you have an allergy-note?'  id='choice_7_28_1'   \/ aria-label=\"Allergies. Do you have an allergy-note?\">\n\t\t\t\t\t\t\t\t<label for='choice_7_28_1' id='label_7_28_1' class='gform-field-label gform-field-label--type-inline'>Allergies. Do you have an allergy-note?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Respiratory disease \/ pulmonary disease'  id='choice_7_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_2' id='label_7_28_2' class='gform-field-label gform-field-label--type-inline'>Respiratory disease \/ pulmonary disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Heart problems \/ heart defect'  id='choice_7_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_3' id='label_7_28_3' class='gform-field-label gform-field-label--type-inline'>Heart problems \/ heart defect<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Epilepsy'  id='choice_7_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_4' id='label_7_28_4' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Pacemaker or implanted defibrillator'  id='choice_7_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_5' id='label_7_28_5' class='gform-field-label gform-field-label--type-inline'>Pacemaker or implanted defibrillator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Osteoporosis'  id='choice_7_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_6' id='label_7_28_6' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Diabetes'  id='choice_7_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_7' id='label_7_28_7' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.8' type='checkbox'  value='Rheumatic disease'  id='choice_7_28_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_8' id='label_7_28_8' class='gform-field-label gform-field-label--type-inline'>Rheumatic disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.9' type='checkbox'  value='Liver disease \/ kidney disease'  id='choice_7_28_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_9' id='label_7_28_9' class='gform-field-label gform-field-label--type-inline'>Liver disease \/ kidney disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.11' type='checkbox'  value='Infectious diseases (jaundice, hepatitis, HIV, tuberculosis)'  id='choice_7_28_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_11' id='label_7_28_11' class='gform-field-label gform-field-label--type-inline'>Infectious diseases (jaundice, hepatitis, HIV, tuberculosis)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.12' type='checkbox'  value='Gastro - intestinal disease'  id='choice_7_28_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_12' id='label_7_28_12' class='gform-field-label gform-field-label--type-inline'>Gastro - intestinal disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.13' type='checkbox'  value='Any other disease:'  id='choice_7_28_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_13' id='label_7_28_13' class='gform-field-label gform-field-label--type-inline'>Any other disease:<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_28_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.14' type='checkbox'  value='No disease. I am healthy.'  id='choice_7_28_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_28_14' id='label_7_28_14' class='gform-field-label gform-field-label--type-inline'>No disease. I am healthy.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_29\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_29'>Illness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_7_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/ aria-label=\"Illness(Required)\"><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_31' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Back'  \/> <input type='button' id='gform_next_button_7_31' 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_7_4' class='gform_page' data-js='page-field-id-31' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_7_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Summary<\/h3><\/div><div id=\"field_7_40\" class=\"gfield gfield--type-html gfield--width-full error-validation-block gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >There is a problem with the input. 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