{"id":9360,"date":"2025-11-21T01:07:03","date_gmt":"2025-11-21T01:07:03","guid":{"rendered":"https:\/\/dreugenelipov.com\/?page_id=9360"},"modified":"2026-02-11T13:34:43","modified_gmt":"2026-02-11T13:34:43","slug":"pre-visit-questionnaire","status":"publish","type":"page","link":"https:\/\/dreugenelipov.com\/es\/pre-visit-questionnaire\/","title":{"rendered":"Cuestionario previo a la visita del Centro Stella"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9360\" class=\"elementor elementor-9360\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1698a6b e-flex e-con-boxed e-con e-parent\" data-id=\"1698a6b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4ab2543 elementor-widget elementor-widget-heading\" data-id=\"4ab2543\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Pre-Visit Questionnaire<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e27fa84 e-con-full e-flex e-con e-parent\" data-id=\"e27fa84\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-af2ec1b e-con-full e-flex e-con e-parent\" data-id=\"af2ec1b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-5c96001 e-flex e-con-boxed e-con e-child\" data-id=\"5c96001\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4557a97 elementor-widget-mobile__width-initial elementor-widget__width-inherit elementor-widget elementor-widget-shortcode\" data-id=\"4557a97\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\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<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Pre-Visit Questionnaire<\/h2>\n                            <p class='gform_description'>Please complete all sections as accurately as possible before your visit.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/es\/wp-json\/wp\/v2\/pages\/9360#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>7<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%;'><span>14%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_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_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_4\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Contact Information<\/h3><\/div><fieldset id=\"field_5_37\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_37'>\n                            \n                            <span id='input_5_37_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.3' id='input_5_37_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_37_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nombre<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_5_203\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_203'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_203' id='input_5_203' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_39'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_39' id='input_5_39' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_39_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_39_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_39' class='gform_hidden' value='https:\/\/dreugenelipov.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_204\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_204'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_204' id='input_5_204' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Weight<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_5_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_36'>Height<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>DOB<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_5_38' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_38_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_38_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_38' class='gform_hidden' value='https:\/\/dreugenelipov.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_68' 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_5_2' class='gform_page' data-js='page-field-id-68' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>I. Chief Complaint (Describe your symptoms):<\/h3>\n<\/div><div id=\"field_5_43\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_43'>Describe your symptoms<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_5_43' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_69' 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_5_69' 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_5_3' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>II. History of Present Illness<\/h3>\n<\/div><div id=\"field_5_45\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_45'>1. When did the symptoms start:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_5_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_45_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_45' class='gform_hidden' value='https:\/\/dreugenelipov.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half 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' >When did symptoms start?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_46'><div class='gchoice gchoice_5_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Unknown'  id='choice_5_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_46_1' id='label_5_46_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'>2. What was the cause of the symptoms?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_5_47' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_48'>3. Describe your symptoms:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_5_48' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_49'>4. What increases your symptoms?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_5_49' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_50'>5. What decreases your symptoms<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_5_50' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >6. Sleep History:<\/div><div id=\"field_5_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_53'>a. What time do you go to bed?<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_54'>b. How many hours does it take you to fall asleep?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_5_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_55'>c. How many times do you wake up at night, and why?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_56'>d. How many hours of sleep do you get per night?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_5_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_57'>e. How many hours of sleep do you require to feel rested?<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col 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' >f. Have you taken sleep medications or natural supplements to help you fall asleep?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_58'>\n\t\t\t<div class='gchoice gchoice_5_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_5_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_5_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_59\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_59'>If yes, please list:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_5_59' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col 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' >g. Do you use alcohol to go to sleep?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_60'>\n\t\t\t<div class='gchoice gchoice_5_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_5_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_60_0' id='label_5_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_5_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_60_1' id='label_5_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_61\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >7. Who is your primary care\/general doctor? When were they last seen?<\/div><div id=\"field_5_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_62'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_63\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_63'>Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_63' id='input_5_63' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_64\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_64'>Last seen:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_64' id='input_5_64' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_64_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_64_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_64' class='gform_hidden' value='https:\/\/dreugenelipov.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_66\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >8. Other providers seen:<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Specialty<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Treatment Provided<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Did it help<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_66_cell1 gform-grid-col' data-label='Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_66\" aria-label='Name, Fila 1' data-aria-label-template='Name, Fila {0}' type='text' name='input_66[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_66_cell2 gform-grid-col' data-label='Specialty'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_66\" aria-label='Specialty, Fila 1' data-aria-label-template='Specialty, Fila {0}' type='text' name='input_66[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_66_cell3 gform-grid-col' data-label='Treatment Provided'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_66\" aria-label='Treatment Provided, Fila 1' data-aria-label-template='Treatment Provided, Fila {0}' type='text' name='input_66[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_66_cell4 gform-grid-col' data-label='Did it help'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_66\" aria-label='Did it help, Fila 1' data-aria-label-template='Did it help, Fila {0}' type='text' name='input_66[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_66'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col 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' >9. Could you be pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_67'>\n\t\t\t<div class='gchoice gchoice_5_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_5_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_0' id='label_5_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_5_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_1' id='label_5_67_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_5_70' 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_5_70' 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_5_4' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_71\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>III. Past History<\/h3>\n<\/div><fieldset id=\"field_5_73\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >1. Allergies:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_73'><div class='gchoice gchoice_5_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='No Know Allergies'  id='choice_5_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_1' id='label_5_73_1' class='gform-field-label gform-field-label--type-inline'>No Know Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Latex'  id='choice_5_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_2' id='label_5_73_2' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.3' type='checkbox'  value='IVP Dye'  id='choice_5_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_3' id='label_5_73_3' class='gform-field-label gform-field-label--type-inline'>IVP Dye<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.4' type='checkbox'  value='Iodine'  id='choice_5_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_4' id='label_5_73_4' class='gform-field-label gform-field-label--type-inline'>Iodine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.5' type='checkbox'  value='Shellfish'  id='choice_5_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_5' id='label_5_73_5' class='gform-field-label gform-field-label--type-inline'>Shellfish<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.6' type='checkbox'  value='Sulfa'  id='choice_5_73_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_6' id='label_5_73_6' class='gform-field-label gform-field-label--type-inline'>Sulfa<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.7' type='checkbox'  value='Penicillin'  id='choice_5_73_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_7' id='label_5_73_7' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_73_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.8' type='checkbox'  value='Other'  id='choice_5_73_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_73_8' id='label_5_73_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_74\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please list<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_74_cell1 gform-grid-col' ><input aria-invalid='false'  aria-describedby=\"gfield_description_5_74\" aria-label='Please list, Fila 1' data-aria-label-template='Please list, Fila {0}' type='text' name='input_74[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_74'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_75\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. Medications For PTSD:<\/legend><div class='gfield_description' id='gfield_description_5_75'>Please list all medications you are currently taking for PTSD\n (Use reverse if more space needed)<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dose<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date Started (MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Prescribing Doctor<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell1 gform-grid-col' data-label='Medication'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_75\" aria-label='Medication, Fila 1' data-aria-label-template='Medication, Fila {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell2 gform-grid-col' data-label='Dose'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_75\" aria-label='Dose, Fila 1' data-aria-label-template='Dose, Fila {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell3 gform-grid-col' data-label='Frequency'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_75\" aria-label='Frequency, Fila 1' data-aria-label-template='Frequency, Fila {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell4 gform-grid-col' data-label='Date Started (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_75\" aria-label='Date Started (MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date Started (MM\/DD\/YYYY), Fila {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_75_cell5 gform-grid-col' data-label='Prescribing Doctor'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_75\" aria-label='Prescribing Doctor, Fila 1' data-aria-label-template='Prescribing Doctor, Fila {0}' type='text' name='input_75[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_76\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >3. Other Medications:<\/legend><div class='gfield_description' id='gfield_description_5_76'>Please list all other medications you are currently taking (prescription and nonprescription, including aspirin, Tylenol, fish oil, etc. Be sure to include any blood\nthinners you are taking \u2013 plavix, coumadin, etc.) (Use reverse if more space needed)<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dose<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date Started(MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Prescribing Doctor<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell1 gform-grid-col' data-label='Medication'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_76\" aria-label='Medication, Fila 1' data-aria-label-template='Medication, Fila {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell2 gform-grid-col' data-label='Dose'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_76\" aria-label='Dose, Fila 1' data-aria-label-template='Dose, Fila {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell3 gform-grid-col' data-label='Frequency'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_76\" aria-label='Frequency, Fila 1' data-aria-label-template='Frequency, Fila {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell4 gform-grid-col' data-label='Date Started(MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_76\" aria-label='Date Started(MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date Started(MM\/DD\/YYYY), Fila {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell5 gform-grid-col' data-label='Prescribing Doctor'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_76\" aria-label='Prescribing Doctor, Fila 1' data-aria-label-template='Prescribing Doctor, Fila {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_77\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >4. Previous Medications\/Natural Supplements<\/legend><div class='gfield_description' id='gfield_description_5_77'>Click the \u201c+\u201d button to add more entries as needed.<\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medication<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Effective? (Yes\/No)<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell1 gform-grid-col' data-label='Medication'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_77\" aria-label='Medication, Fila 1' data-aria-label-template='Medication, Fila {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_77_cell2 gform-grid-col' data-label='Effective? (Yes\/No)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_77\" aria-label='Effective? (Yes\/No), Fila 1' data-aria-label-template='Effective? (Yes\/No), Fila {0}' type='text' name='input_77[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >5. Previous Hospitalizations without surgery<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_79'>\n\t\t\t<div class='gchoice gchoice_5_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_5_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_79_0' id='label_5_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_5_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_81\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Include year and physician&#039;s name<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date of Hospitalization (MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Physician&#039;s Name<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_81_cell1 gform-grid-col' data-label='Date of Hospitalization (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_81\" aria-label='Date of Hospitalization (MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date of Hospitalization (MM\/DD\/YYYY), Fila {0}' type='text' name='input_81[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_81_cell2 gform-grid-col' data-label='Physician&#039;s Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_81\" aria-label='Physician&#039;s Name, Fila 1' data-aria-label-template='Physician&#039;s Name, Fila {0}' type='text' name='input_81[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_81'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >6. Past Surgical History<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_84'>\n\t\t\t<div class='gchoice gchoice_5_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_5_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_0' id='label_5_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_5_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_83\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Include year and physician&#039;s name<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date of Hospitalization (MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Physician&#039;s Name<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_83_cell1 gform-grid-col' data-label='Date of Hospitalization (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_83\" aria-label='Date of Hospitalization (MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date of Hospitalization (MM\/DD\/YYYY), Fila {0}' type='text' name='input_83[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_83_cell2 gform-grid-col' data-label='Physician&#039;s Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_83\" aria-label='Physician&#039;s Name, Fila 1' data-aria-label-template='Physician&#039;s Name, Fila {0}' type='text' name='input_83[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_83'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Have you ever had surgery on your neck?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_82'>\n\t\t\t<div class='gchoice gchoice_5_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_5_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_0' id='label_5_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_5_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >7. Psychiatric Hospitalizations:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_85'>\n\t\t\t<div class='gchoice gchoice_5_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_5_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_85_0' id='label_5_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_5_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_85_1' id='label_5_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_86\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Include year and physician&#039;s name<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date of Hospitalization (MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Physician&#039;s Name<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell1 gform-grid-col' data-label='Date of Hospitalization (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_86\" aria-label='Date of Hospitalization (MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date of Hospitalization (MM\/DD\/YYYY), Fila {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell2 gform-grid-col' data-label='Physician&#039;s Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_86\" aria-label='Physician&#039;s Name, Fila 1' data-aria-label-template='Physician&#039;s Name, Fila {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_86'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >8. Hospitalization due to suicide attempt:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_87'>\n\t\t\t<div class='gchoice gchoice_5_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='Yes'  id='choice_5_87_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_0' id='label_5_87_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='No'  id='choice_5_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_87_1' id='label_5_87_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_88\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Include year and physician&#039;s name<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date of Hospitalization (MM\/DD\/YYYY)<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Physician&#039;s Name<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_88_cell1 gform-grid-col' data-label='Date of Hospitalization (MM\/DD\/YYYY)'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_88\" aria-label='Date of Hospitalization (MM\/DD\/YYYY), Fila 1' data-aria-label-template='Date of Hospitalization (MM\/DD\/YYYY), Fila {0}' type='text' name='input_88[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_88_cell2 gform-grid-col' data-label='Physician&#039;s Name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_88\" aria-label='Physician&#039;s Name, Fila 1' data-aria-label-template='Physician&#039;s Name, Fila {0}' type='text' name='input_88[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_88'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_89' 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_5_89' 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_5_5' class='gform_page' data-js='page-field-id-89' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_90\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>IV. Other History Questions:<\/h3>\n<\/div><fieldset id=\"field_5_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Family Medical History<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_91'>\n\t\t\t<div class='gchoice gchoice_5_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_5_91_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_91\"   \/>\n\t\t\t\t\t<label for='choice_5_91_0' id='label_5_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No Problem'  id='choice_5_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_91_1' id='label_5_91_1' class='gform-field-label gform-field-label--type-inline'>No Problem<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_91'>Answers should be mom, dad, brother, sister, aunt, uncle, etc.<\/div><\/fieldset><fieldset id=\"field_5_92\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Diagnosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_92'><div class='gchoice gchoice_5_92_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.1' type='checkbox'  value='Arthritis'  id='choice_5_92_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_1' id='label_5_92_1' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.2' type='checkbox'  value='Fibromyalgia'  id='choice_5_92_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_2' id='label_5_92_2' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.3' type='checkbox'  value='Lupus'  id='choice_5_92_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_3' id='label_5_92_3' class='gform-field-label gform-field-label--type-inline'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.4' type='checkbox'  value='Multiple Sclerosis'  id='choice_5_92_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_4' id='label_5_92_4' class='gform-field-label gform-field-label--type-inline'>Multiple Sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.5' type='checkbox'  value='Epilepsy'  id='choice_5_92_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_5' id='label_5_92_5' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.6' type='checkbox'  value='Depression'  id='choice_5_92_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_6' id='label_5_92_6' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.7' type='checkbox'  value='Schizophrenia'  id='choice_5_92_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_7' id='label_5_92_7' class='gform-field-label gform-field-label--type-inline'>Schizophrenia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.8' type='checkbox'  value='Alcoholism'  id='choice_5_92_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_8' id='label_5_92_8' class='gform-field-label gform-field-label--type-inline'>Alcoholism<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.9' type='checkbox'  value='Addictive Behavior'  id='choice_5_92_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_9' id='label_5_92_9' class='gform-field-label gform-field-label--type-inline'>Addictive Behavior<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.11' type='checkbox'  value='Suicidal Ideation'  id='choice_5_92_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_11' id='label_5_92_11' class='gform-field-label gform-field-label--type-inline'>Suicidal Ideation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.12' type='checkbox'  value='PTSD'  id='choice_5_92_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_12' id='label_5_92_12' class='gform-field-label gform-field-label--type-inline'>PTSD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.13' type='checkbox'  value='High Blood Pressure'  id='choice_5_92_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_13' id='label_5_92_13' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.14' type='checkbox'  value='Heart Attack'  id='choice_5_92_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_14' id='label_5_92_14' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.15' type='checkbox'  value='Heart Disease'  id='choice_5_92_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_15' id='label_5_92_15' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.16' type='checkbox'  value='Diabetes'  id='choice_5_92_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_16' id='label_5_92_16' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.17' type='checkbox'  value='Bronchial Asthma'  id='choice_5_92_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_17' id='label_5_92_17' class='gform-field-label gform-field-label--type-inline'>Bronchial Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.18' type='checkbox'  value='Bleeding Disorder'  id='choice_5_92_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_18' id='label_5_92_18' class='gform-field-label gform-field-label--type-inline'>Bleeding Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.19' type='checkbox'  value='Hepatitis'  id='choice_5_92_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_19' id='label_5_92_19' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.21' type='checkbox'  value='Thyroid Disorders'  id='choice_5_92_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_21' id='label_5_92_21' class='gform-field-label gform-field-label--type-inline'>Thyroid Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.22' type='checkbox'  value='Rehab Center'  id='choice_5_92_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_22' id='label_5_92_22' class='gform-field-label gform-field-label--type-inline'>Rehab Center<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.23' type='checkbox'  value='Suicide Attempt'  id='choice_5_92_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_23' id='label_5_92_23' class='gform-field-label gform-field-label--type-inline'>Suicide Attempt<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.24' type='checkbox'  value='HIV'  id='choice_5_92_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_24' id='label_5_92_24' class='gform-field-label gform-field-label--type-inline'>HIV<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_92_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.25' type='checkbox'  value='Cancer'  id='choice_5_92_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_92_25' id='label_5_92_25' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_93\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Family Medical History<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Diagnosis<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Relationship to You<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Additional Details<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_93_cell1 gform-grid-col' data-label='Diagnosis'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_93\" aria-label='Diagnosis, Fila 1' data-aria-label-template='Diagnosis, Fila {0}' type='text' name='input_93[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_93_cell2 gform-grid-col' data-label='Relationship to You'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_93\" aria-label='Relationship to You, Fila 1' data-aria-label-template='Relationship to You, Fila {0}' type='text' name='input_93[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_93_cell3 gform-grid-col' data-label='Additional Details'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_93\" aria-label='Additional Details, Fila 1' data-aria-label-template='Additional Details, Fila {0}' type='text' name='input_93[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_93'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><div id=\"field_5_95\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >2. Social History\n<\/div><fieldset id=\"field_5_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >A. Smoking:<\/legend><div class='gfield_description' id='gfield_description_5_96'>Do you smoke now?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_96'>\n\t\t\t<div class='gchoice gchoice_5_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_5_96_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_96\"   \/>\n\t\t\t\t\t<label for='choice_5_96_0' id='label_5_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_5_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_96_1' id='label_5_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_97'>If yes, when did you start?<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_5_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_98\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Provide Details Below<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Cigarettes\/Cigars\/Pipe<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Per day?<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_98_cell1 gform-grid-col' data-label='Cigarettes\/Cigars\/Pipe'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_98\" aria-label='Cigarettes\/Cigars\/Pipe, Fila 1' data-aria-label-template='Cigarettes\/Cigars\/Pipe, Fila {0}' type='text' name='input_98[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_98_cell2 gform-grid-col' data-label='Per day?'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_5_98\" aria-label='Per day?, Fila 1' data-aria-label-template='Per day?, Fila {0}' type='text' name='input_98[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_98'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><fieldset id=\"field_5_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >B. Alcohol:<\/legend><div class='gfield_description' id='gfield_description_5_99'>Do you drink alcohol?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_99'>\n\t\t\t<div class='gchoice gchoice_5_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_5_99_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_99\"   \/>\n\t\t\t\t\t<label for='choice_5_99_0' id='label_5_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_5_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_99_1' id='label_5_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_100'>How much?<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_5_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever had a problem with alcohol?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_101'>\n\t\t\t<div class='gchoice gchoice_5_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_5_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_101_0' id='label_5_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_5_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_101_1' id='label_5_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_101_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Cirrhosis of Liver'  id='choice_5_101_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_101_2' id='label_5_101_2' class='gform-field-label gform-field-label--type-inline'>Cirrhosis of Liver<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_102\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_102'>Please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_5_102' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >C. Caffeinated Drinks:<\/legend><div class='gfield_description' id='gfield_description_5_103'>Do you consume drinks with caffeine?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_103'>\n\t\t\t<div class='gchoice gchoice_5_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_5_103_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_103\"   \/>\n\t\t\t\t\t<label for='choice_5_103_0' id='label_5_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_5_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_103_1' id='label_5_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_104\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >If yes, which drinks do you consume? (Select all that apply)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_104'><div class='gchoice gchoice_5_104_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.1' type='checkbox'  value='Coffee'  id='choice_5_104_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_104_1' id='label_5_104_1' class='gform-field-label gform-field-label--type-inline'>Coffee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_104_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.2' type='checkbox'  value='Tea'  id='choice_5_104_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_104_2' id='label_5_104_2' class='gform-field-label gform-field-label--type-inline'>Tea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_104_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.3' type='checkbox'  value='Iced Tea'  id='choice_5_104_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_104_3' id='label_5_104_3' class='gform-field-label gform-field-label--type-inline'>Iced Tea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_104_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.4' type='checkbox'  value='Colas'  id='choice_5_104_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_104_4' id='label_5_104_4' class='gform-field-label gform-field-label--type-inline'>Colas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_105\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >D. Illicit Drugs:<\/legend><div class='gfield_description' id='gfield_description_5_105'>Do you use any street drugs?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_105'>\n\t\t\t<div class='gchoice gchoice_5_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_5_105_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_105\"   \/>\n\t\t\t\t\t<label for='choice_5_105_0' id='label_5_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_5_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_105_1' id='label_5_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_106\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_106'>Please explain<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_5_106' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you use marijuana?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_107'>\n\t\t\t<div class='gchoice gchoice_5_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Yes'  id='choice_5_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_107_0' id='label_5_107_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='No'  id='choice_5_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_107_1' id='label_5_107_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_4col 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' >E. Marital Status:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_109'>\n\t\t\t<div class='gchoice gchoice_5_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Married'  id='choice_5_109_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_109_0' id='label_5_109_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Single'  id='choice_5_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_109_1' id='label_5_109_1' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_109_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Divorced'  id='choice_5_109_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_109_2' id='label_5_109_2' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_109_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Widowed'  id='choice_5_109_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_109_3' id='label_5_109_3' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_110'>No. of children:<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_5_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_111\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_4col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >F. Criminal History:<\/legend><div class='gfield_description' id='gfield_description_5_111'>Have you ever been convicted of a crime?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_111'>\n\t\t\t<div class='gchoice gchoice_5_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Yes'  id='choice_5_111_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_111\"   \/>\n\t\t\t\t\t<label for='choice_5_111_0' id='label_5_111_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='No'  id='choice_5_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_111_1' id='label_5_111_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_112'>If yes, what was the nature of the offense leading to conviction?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_5_112' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_113\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_113'>How recent was such offense?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_5_113' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_4col gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G. Work History:<\/legend><div class='gfield_description' id='gfield_description_5_114'>1. Currently at work:<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_114'>\n\t\t\t<div class='gchoice gchoice_5_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Employed'  id='choice_5_114_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_114\"   \/>\n\t\t\t\t\t<label for='choice_5_114_0' id='label_5_114_0' class='gform-field-label gform-field-label--type-inline'>Employed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Full-Time'  id='choice_5_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_114_1' id='label_5_114_1' class='gform-field-label gform-field-label--type-inline'>Full-Time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_114_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Part-Time'  id='choice_5_114_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_114_2' id='label_5_114_2' class='gform-field-label gform-field-label--type-inline'>Part-Time<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_114_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Self-Employed'  id='choice_5_114_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_114_3' id='label_5_114_3' class='gform-field-label gform-field-label--type-inline'>Self-Employed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_115\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_115'>Occupation:<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_5_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_116\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_116'>What shift do you work:<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_5_116' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_117\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_117'>How many hours\/day?<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_5_117' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_118'>How many hours\/week?<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_5_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_119\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_119'>Describe job duties:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_119' id='input_5_119' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_120\" class=\"gfield gfield--type-list gfield--input-type-list 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 gfield_label_before_complex' >Hours you spend<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">standing<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">sitting<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">walking<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">bending<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">computer work<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell1 gform-grid-col' data-label='standing'><input aria-invalid='false'   aria-label='standing, Fila 1' data-aria-label-template='standing, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell2 gform-grid-col' data-label='sitting'><input aria-invalid='false'   aria-label='sitting, Fila 1' data-aria-label-template='sitting, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell3 gform-grid-col' data-label='walking'><input aria-invalid='false'   aria-label='walking, Fila 1' data-aria-label-template='walking, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell4 gform-grid-col' data-label='bending'><input aria-invalid='false'   aria-label='bending, Fila 1' data-aria-label-template='bending, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell5 gform-grid-col' data-label='computer work'><input aria-invalid='false'   aria-label='computer work, Fila 1' data-aria-label-template='computer work, Fila {0}' type='text' name='input_120[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_4col gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Currently not at work:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_121'>\n\t\t\t<div class='gchoice gchoice_5_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Unemployed'  id='choice_5_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_121_0' id='label_5_121_0' class='gform-field-label gform-field-label--type-inline'>Unemployed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Retired'  id='choice_5_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_121_1' id='label_5_121_1' class='gform-field-label gform-field-label--type-inline'>Retired<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_121_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Disability'  id='choice_5_121_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_121_2' id='label_5_121_2' class='gform-field-label gform-field-label--type-inline'>Disability<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_121_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Other'  id='choice_5_121_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_121_3' id='label_5_121_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_122\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_122'>Specify:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_122' id='input_5_122' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_123' 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_5_123' 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_5_6' class='gform_page' data-js='page-field-id-123' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_124\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>V. Review of Systems:<\/h3><\/div><fieldset id=\"field_5_127\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >1. Constitutional Symptoms:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_127'><div class='gchoice gchoice_5_127_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.1' type='checkbox'  value='Weight Loss'  id='choice_5_127_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_1' id='label_5_127_1' class='gform-field-label gform-field-label--type-inline'>Weight Loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.2' type='checkbox'  value='Weight Gain'  id='choice_5_127_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_2' id='label_5_127_2' class='gform-field-label gform-field-label--type-inline'>Weight Gain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.3' type='checkbox'  value='Trying to lose weight'  id='choice_5_127_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_3' id='label_5_127_3' class='gform-field-label gform-field-label--type-inline'>Trying to lose weight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.4' type='checkbox'  value='Recurrent Fever'  id='choice_5_127_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_4' id='label_5_127_4' class='gform-field-label gform-field-label--type-inline'>Recurrent Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.5' type='checkbox'  value='General Weakness'  id='choice_5_127_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_5' id='label_5_127_5' class='gform-field-label gform-field-label--type-inline'>General Weakness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.6' type='checkbox'  value='Fatigue'  id='choice_5_127_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_6' id='label_5_127_6' class='gform-field-label gform-field-label--type-inline'>Fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.7' type='checkbox'  value='Chills'  id='choice_5_127_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_7' id='label_5_127_7' class='gform-field-label gform-field-label--type-inline'>Chills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.8' type='checkbox'  value='Insomnia'  id='choice_5_127_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_8' id='label_5_127_8' class='gform-field-label gform-field-label--type-inline'>Insomnia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_127_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.9' type='checkbox'  value='Hypersomnolence'  id='choice_5_127_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_127_9' id='label_5_127_9' class='gform-field-label gform-field-label--type-inline'>Hypersomnolence<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_126\" class=\"gfield gfield--type-list gfield--input-type-list 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 gfield_label_before_complex' >Weight Loss<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">lbs<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">during<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell1 gform-grid-col' data-label='lbs'><input aria-invalid='false'   aria-label='lbs, Fila 1' data-aria-label-template='lbs, Fila {0}' type='text' name='input_126[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_126_cell2 gform-grid-col' data-label='during'><input aria-invalid='false'   aria-label='during, Fila 1' data-aria-label-template='during, Fila {0}' type='text' name='input_126[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_128\" class=\"gfield gfield--type-list gfield--input-type-list 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 gfield_label_before_complex' >Weight Gain<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">lbs<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">during<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_128_cell1 gform-grid-col' data-label='lbs'><input aria-invalid='false'   aria-label='lbs, Fila 1' data-aria-label-template='lbs, Fila {0}' type='text' name='input_128[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_128_cell2 gform-grid-col' data-label='during'><input aria-invalid='false'   aria-label='during, Fila 1' data-aria-label-template='during, Fila {0}' type='text' name='input_128[]' value=''   \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_5_146\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >2. Neurological<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_130'>\n\t\t\t<div class='gchoice gchoice_5_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Yes'  id='choice_5_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_130_0' id='label_5_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_5_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_130_1' id='label_5_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_129\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_129'><div class='gchoice gchoice_5_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='Incontinence of urine or stool'  id='choice_5_129_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_1' id='label_5_129_1' class='gform-field-label gform-field-label--type-inline'>Incontinence of urine or stool<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.2' type='checkbox'  value='Frequent or Recurrent Headaches'  id='choice_5_129_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_2' id='label_5_129_2' class='gform-field-label gform-field-label--type-inline'>Frequent or Recurrent Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.3' type='checkbox'  value='Fainting'  id='choice_5_129_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_3' id='label_5_129_3' class='gform-field-label gform-field-label--type-inline'>Fainting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.4' type='checkbox'  value='Blackouts'  id='choice_5_129_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_4' id='label_5_129_4' class='gform-field-label gform-field-label--type-inline'>Blackouts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.5' type='checkbox'  value='Stroke'  id='choice_5_129_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_5' id='label_5_129_5' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.6' type='checkbox'  value='Gait Difficulties'  id='choice_5_129_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_6' id='label_5_129_6' class='gform-field-label gform-field-label--type-inline'>Gait Difficulties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.7' type='checkbox'  value='Paralysis'  id='choice_5_129_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_7' id='label_5_129_7' class='gform-field-label gform-field-label--type-inline'>Paralysis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.8' type='checkbox'  value='Frequent Falls'  id='choice_5_129_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_8' id='label_5_129_8' class='gform-field-label gform-field-label--type-inline'>Frequent Falls<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.9' type='checkbox'  value='Tremors'  id='choice_5_129_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_9' id='label_5_129_9' class='gform-field-label gform-field-label--type-inline'>Tremors<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.11' type='checkbox'  value='Neuropathy'  id='choice_5_129_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_11' id='label_5_129_11' class='gform-field-label gform-field-label--type-inline'>Neuropathy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.12' type='checkbox'  value='Weakness'  id='choice_5_129_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_12' id='label_5_129_12' class='gform-field-label gform-field-label--type-inline'>Weakness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.13' type='checkbox'  value='Seizures'  id='choice_5_129_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_13' id='label_5_129_13' class='gform-field-label gform-field-label--type-inline'>Seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.14' type='checkbox'  value='Epilepsy'  id='choice_5_129_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_14' id='label_5_129_14' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.15' type='checkbox'  value='Polio'  id='choice_5_129_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_15' id='label_5_129_15' class='gform-field-label gform-field-label--type-inline'>Polio<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.16' type='checkbox'  value='Dizzy Spells'  id='choice_5_129_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_16' id='label_5_129_16' class='gform-field-label gform-field-label--type-inline'>Dizzy Spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.17' type='checkbox'  value='Vertigo'  id='choice_5_129_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_17' id='label_5_129_17' class='gform-field-label gform-field-label--type-inline'>Vertigo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.18' type='checkbox'  value='Problems with concentration'  id='choice_5_129_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_18' id='label_5_129_18' class='gform-field-label gform-field-label--type-inline'>Problems with concentration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.19' type='checkbox'  value='Lupus'  id='choice_5_129_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_19' id='label_5_129_19' class='gform-field-label gform-field-label--type-inline'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.21' type='checkbox'  value='Alzheimer&#039;s'  id='choice_5_129_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_21' id='label_5_129_21' class='gform-field-label gform-field-label--type-inline'>Alzheimer's<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.22' type='checkbox'  value='Problems with thinking or thought process'  id='choice_5_129_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_22' id='label_5_129_22' class='gform-field-label gform-field-label--type-inline'>Problems with thinking or thought process<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.23' type='checkbox'  value='Pain with light touch to skin'  id='choice_5_129_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_23' id='label_5_129_23' class='gform-field-label gform-field-label--type-inline'>Pain with light touch to skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.24' type='checkbox'  value='Problems with memory'  id='choice_5_129_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_24' id='label_5_129_24' class='gform-field-label gform-field-label--type-inline'>Problems with memory<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.25' type='checkbox'  value='Confusion'  id='choice_5_129_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_25' id='label_5_129_25' class='gform-field-label gform-field-label--type-inline'>Confusion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.26' type='checkbox'  value='Multiple Sclerosis'  id='choice_5_129_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_26' id='label_5_129_26' class='gform-field-label gform-field-label--type-inline'>Multiple Sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_129_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.27' type='checkbox'  value='Head Injury'  id='choice_5_129_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_129_27' id='label_5_129_27' class='gform-field-label gform-field-label--type-inline'>Head Injury<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_147\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >3. Hematologic<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_131'>\n\t\t\t<div class='gchoice gchoice_5_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Yes'  id='choice_5_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_131_0' id='label_5_131_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='No'  id='choice_5_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_131_1' id='label_5_131_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_132\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_132'><div class='gchoice gchoice_5_132_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.1' type='checkbox'  value='Blood Transfusion'  id='choice_5_132_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_1' id='label_5_132_1' class='gform-field-label gform-field-label--type-inline'>Blood Transfusion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_132_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.2' type='checkbox'  value='Bleeding Disorder (Hemophilia)'  id='choice_5_132_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_2' id='label_5_132_2' class='gform-field-label gform-field-label--type-inline'>Bleeding Disorder (Hemophilia)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_132_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.3' type='checkbox'  value='Anemia (Iron deficiency, Pernicious, Sickel cell)'  id='choice_5_132_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_3' id='label_5_132_3' class='gform-field-label gform-field-label--type-inline'>Anemia (Iron deficiency, Pernicious, Sickel cell)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_132_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.4' type='checkbox'  value='Easy Bruising'  id='choice_5_132_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_4' id='label_5_132_4' class='gform-field-label gform-field-label--type-inline'>Easy Bruising<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_132_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.5' type='checkbox'  value='IV Drug Use'  id='choice_5_132_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_5' id='label_5_132_5' class='gform-field-label gform-field-label--type-inline'>IV Drug Use<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_132_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.6' type='checkbox'  value='Enlarged Lymph Nodes'  id='choice_5_132_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_132_6' id='label_5_132_6' class='gform-field-label gform-field-label--type-inline'>Enlarged Lymph Nodes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_148\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >4. Infectious Disease<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_134'>\n\t\t\t<div class='gchoice gchoice_5_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Yes'  id='choice_5_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_134_0' id='label_5_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_5_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_134_1' id='label_5_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_133\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_133'><div class='gchoice gchoice_5_133_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.1' type='checkbox'  value='Hepatitis'  id='choice_5_133_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_1' id='label_5_133_1' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.2' type='checkbox'  value='Type A'  id='choice_5_133_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_2' id='label_5_133_2' class='gform-field-label gform-field-label--type-inline'>Type A<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.3' type='checkbox'  value='Type B'  id='choice_5_133_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_3' id='label_5_133_3' class='gform-field-label gform-field-label--type-inline'>Type B<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.4' type='checkbox'  value='Type C'  id='choice_5_133_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_4' id='label_5_133_4' class='gform-field-label gform-field-label--type-inline'>Type C<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.5' type='checkbox'  value='HIV'  id='choice_5_133_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_5' id='label_5_133_5' class='gform-field-label gform-field-label--type-inline'>HIV<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.6' type='checkbox'  value='Herpes'  id='choice_5_133_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_6' id='label_5_133_6' class='gform-field-label gform-field-label--type-inline'>Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.7' type='checkbox'  value='Shingles'  id='choice_5_133_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_7' id='label_5_133_7' class='gform-field-label gform-field-label--type-inline'>Shingles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_133_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.8' type='checkbox'  value='TB (Tuberculosis)'  id='choice_5_133_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_133_8' id='label_5_133_8' class='gform-field-label gform-field-label--type-inline'>TB (Tuberculosis)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_149\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >5. Psychiatric<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_136'>\n\t\t\t<div class='gchoice gchoice_5_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_5_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_136_0' id='label_5_136_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_5_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_136_1' id='label_5_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_135\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_135'><div class='gchoice gchoice_5_135_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.1' type='checkbox'  value='Suicidal Thoughts'  id='choice_5_135_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_1' id='label_5_135_1' class='gform-field-label gform-field-label--type-inline'>Suicidal Thoughts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.2' type='checkbox'  value='Suicide Attempt'  id='choice_5_135_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_2' id='label_5_135_2' class='gform-field-label gform-field-label--type-inline'>Suicide Attempt<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.3' type='checkbox'  value='Schizophrenia'  id='choice_5_135_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_3' id='label_5_135_3' class='gform-field-label gform-field-label--type-inline'>Schizophrenia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.4' type='checkbox'  value='Alcohol\/Drug Abuse'  id='choice_5_135_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_4' id='label_5_135_4' class='gform-field-label gform-field-label--type-inline'>Alcohol\/Drug Abuse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.5' type='checkbox'  value='Crying Spells'  id='choice_5_135_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_5' id='label_5_135_5' class='gform-field-label gform-field-label--type-inline'>Crying Spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.6' type='checkbox'  value='Mood Swings'  id='choice_5_135_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_6' id='label_5_135_6' class='gform-field-label gform-field-label--type-inline'>Mood Swings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.7' type='checkbox'  value='Suicide attempt requiring hospitalization'  id='choice_5_135_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_7' id='label_5_135_7' class='gform-field-label gform-field-label--type-inline'>Suicide attempt requiring hospitalization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.8' type='checkbox'  value='Depressed'  id='choice_5_135_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_8' id='label_5_135_8' class='gform-field-label gform-field-label--type-inline'>Depressed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.9' type='checkbox'  value='Anxious'  id='choice_5_135_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_9' id='label_5_135_9' class='gform-field-label gform-field-label--type-inline'>Anxious<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.11' type='checkbox'  value='Shaky'  id='choice_5_135_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_11' id='label_5_135_11' class='gform-field-label gform-field-label--type-inline'>Shaky<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.12' type='checkbox'  value='Agitated'  id='choice_5_135_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_12' id='label_5_135_12' class='gform-field-label gform-field-label--type-inline'>Agitated<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.13' type='checkbox'  value='Obsessive Compulsive Disorder'  id='choice_5_135_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_13' id='label_5_135_13' class='gform-field-label gform-field-label--type-inline'>Obsessive Compulsive Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.14' type='checkbox'  value='Nervousness'  id='choice_5_135_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_14' id='label_5_135_14' class='gform-field-label gform-field-label--type-inline'>Nervousness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.15' type='checkbox'  value='Post Traumatic Stress Disorder'  id='choice_5_135_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_15' id='label_5_135_15' class='gform-field-label gform-field-label--type-inline'>Post Traumatic Stress Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.16' type='checkbox'  value='Sexual Abuse History'  id='choice_5_135_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_16' id='label_5_135_16' class='gform-field-label gform-field-label--type-inline'>Sexual Abuse History<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.17' type='checkbox'  value='Domestic Violence'  id='choice_5_135_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_17' id='label_5_135_17' class='gform-field-label gform-field-label--type-inline'>Domestic Violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.18' type='checkbox'  value='Panic Episode'  id='choice_5_135_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_18' id='label_5_135_18' class='gform-field-label gform-field-label--type-inline'>Panic Episode<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.19' type='checkbox'  value='Paranoia'  id='choice_5_135_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_19' id='label_5_135_19' class='gform-field-label gform-field-label--type-inline'>Paranoia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.21' type='checkbox'  value='Hallucinations'  id='choice_5_135_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_21' id='label_5_135_21' class='gform-field-label gform-field-label--type-inline'>Hallucinations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_135_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.22' type='checkbox'  value='Admission to detox center'  id='choice_5_135_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_135_22' id='label_5_135_22' class='gform-field-label gform-field-label--type-inline'>Admission to detox center<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_137'>Suicide Attempt- If yes, when was last attempt?<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_5_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Admission to detox center (if yes, what for?)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_139'><div class='gchoice gchoice_5_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='Alcohol'  id='choice_5_139_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_139_1' id='label_5_139_1' class='gform-field-label gform-field-label--type-inline'>Alcohol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='Opioids'  id='choice_5_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_139_2' id='label_5_139_2' class='gform-field-label gform-field-label--type-inline'>Opioids<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='Other'  id='choice_5_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_139_3' id='label_5_139_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_140'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_5_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >Have you had any previous hospitalizations for psychiatric care or treatment<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_141'>\n\t\t\t<div class='gchoice gchoice_5_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_5_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_141_0' id='label_5_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_5_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_141_1' id='label_5_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_142'>Please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_5_142' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >History of substance abuse or rehab<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_143'>\n\t\t\t<div class='gchoice gchoice_5_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='Yes'  id='choice_5_143_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_143_0' id='label_5_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='No'  id='choice_5_143_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_143_1' id='label_5_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_150\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >6. NSAIDS\/Anti-Inflammatory<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_144'>\n\t\t\t<div class='gchoice gchoice_5_144_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='Yes'  id='choice_5_144_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_144_0' id='label_5_144_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_144_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='No'  id='choice_5_144_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_144_1' id='label_5_144_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_154\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List name, frequency, dosage (i.e. advil, Ibuprofen, Celebrex, etc.)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">List name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_154_cell1 gform-grid-col' data-label='List name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_154\" aria-label='List name, Fila 1' data-aria-label-template='List name, Fila {0}' type='text' name='input_154[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_154_cell2 gform-grid-col' data-label='Frequency'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_154\" aria-label='Frequency, Fila 1' data-aria-label-template='Frequency, Fila {0}' type='text' name='input_154[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_154_cell3 gform-grid-col' data-label='Dosage'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_154\" aria-label='Dosage, Fila 1' data-aria-label-template='Dosage, Fila {0}' type='text' name='input_154[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_154'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><div id=\"field_5_151\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >7. Blood Thinners<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_155'>\n\t\t\t<div class='gchoice gchoice_5_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Yes'  id='choice_5_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_155_0' id='label_5_155_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='No'  id='choice_5_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_155_1' id='label_5_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_152\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List name, frequency, dosage (i.e. Coumadin, Aspirin, Excedrin, Vitamin E, Plavix, Xeralto, garlic, fish oil, etc.)<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">List name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frequency<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosage<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_152_cell1 gform-grid-col' data-label='List name'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_152\" aria-label='List name, Fila 1' data-aria-label-template='List name, Fila {0}' type='text' name='input_152[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_152_cell2 gform-grid-col' data-label='Frequency'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_152\" aria-label='Frequency, Fila 1' data-aria-label-template='Frequency, Fila {0}' type='text' name='input_152[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_152_cell3 gform-grid-col' data-label='Dosage'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_152\" aria-label='Dosage, Fila 1' data-aria-label-template='Dosage, Fila {0}' type='text' name='input_152[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='A\u00f1adir otra fila' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Eliminar fila 1' data-aria-label-template='Eliminar fila {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_152'>Click the \u201c+\u201d button to add more entries as needed.<\/div><\/fieldset><div id=\"field_5_156\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >8. Musculoskeletal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_157'>\n\t\t\t<div class='gchoice gchoice_5_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes'  id='choice_5_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_157_0' id='label_5_157_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No Problems'  id='choice_5_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_157_1' id='label_5_157_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_158\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_158'><div class='gchoice gchoice_5_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Muscle Cramps'  id='choice_5_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_1' id='label_5_158_1' class='gform-field-label gform-field-label--type-inline'>Muscle Cramps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.2' type='checkbox'  value='Stiff Joints'  id='choice_5_158_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_2' id='label_5_158_2' class='gform-field-label gform-field-label--type-inline'>Stiff Joints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.3' type='checkbox'  value='Swelling of Joints'  id='choice_5_158_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_3' id='label_5_158_3' class='gform-field-label gform-field-label--type-inline'>Swelling of Joints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.4' type='checkbox'  value='Generalized Arthritis'  id='choice_5_158_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_4' id='label_5_158_4' class='gform-field-label gform-field-label--type-inline'>Generalized Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.5' type='checkbox'  value='Rheumatoid Arthritis'  id='choice_5_158_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_5' id='label_5_158_5' class='gform-field-label gform-field-label--type-inline'>Rheumatoid Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.6' type='checkbox'  value='Fibromyalgia Syndrome'  id='choice_5_158_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_6' id='label_5_158_6' class='gform-field-label gform-field-label--type-inline'>Fibromyalgia Syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.7' type='checkbox'  value='Osteoporosis'  id='choice_5_158_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_7' id='label_5_158_7' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.8' type='checkbox'  value='Neck Pain'  id='choice_5_158_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_8' id='label_5_158_8' class='gform-field-label gform-field-label--type-inline'>Neck Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.9' type='checkbox'  value='Upper Back Pain'  id='choice_5_158_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_9' id='label_5_158_9' class='gform-field-label gform-field-label--type-inline'>Upper Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.11' type='checkbox'  value='Middle Back Pain'  id='choice_5_158_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_11' id='label_5_158_11' class='gform-field-label gform-field-label--type-inline'>Middle Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.12' type='checkbox'  value='Lower Back Pain'  id='choice_5_158_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_12' id='label_5_158_12' class='gform-field-label gform-field-label--type-inline'>Lower Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.13' type='checkbox'  value='Heel Spur(s)'  id='choice_5_158_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_13' id='label_5_158_13' class='gform-field-label gform-field-label--type-inline'>Heel Spur(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.14' type='checkbox'  value='Joint Pain'  id='choice_5_158_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_14' id='label_5_158_14' class='gform-field-label gform-field-label--type-inline'>Joint Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.15' type='checkbox'  value='Hardware'  id='choice_5_158_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_15' id='label_5_158_15' class='gform-field-label gform-field-label--type-inline'>Hardware<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.16' type='checkbox'  value='Deformity'  id='choice_5_158_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_16' id='label_5_158_16' class='gform-field-label gform-field-label--type-inline'>Deformity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.17' type='checkbox'  value='Limited Range of Motion'  id='choice_5_158_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_17' id='label_5_158_17' class='gform-field-label gform-field-label--type-inline'>Limited Range of Motion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.18' type='checkbox'  value='Abnormal sound when moving joint'  id='choice_5_158_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_18' id='label_5_158_18' class='gform-field-label gform-field-label--type-inline'>Abnormal sound when moving joint<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.19' type='checkbox'  value='Gout'  id='choice_5_158_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_19' id='label_5_158_19' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.21' type='checkbox'  value='Difficulty with walking'  id='choice_5_158_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_21' id='label_5_158_21' class='gform-field-label gform-field-label--type-inline'>Difficulty with walking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.22' type='checkbox'  value='Pain in feet'  id='choice_5_158_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_22' id='label_5_158_22' class='gform-field-label gform-field-label--type-inline'>Pain in feet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.23' type='checkbox'  value='Pain with light touch of skin'  id='choice_5_158_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_23' id='label_5_158_23' class='gform-field-label gform-field-label--type-inline'>Pain with light touch of skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.24' type='checkbox'  value='Cold Upper Extremity(ies)'  id='choice_5_158_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_24' id='label_5_158_24' class='gform-field-label gform-field-label--type-inline'>Cold Upper Extremity(ies)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.25' type='checkbox'  value='Cold Lower Extremity(ies)'  id='choice_5_158_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_25' id='label_5_158_25' class='gform-field-label gform-field-label--type-inline'>Cold Lower Extremity(ies)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.26' type='checkbox'  value='Painful light touch to skin'  id='choice_5_158_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_26' id='label_5_158_26' class='gform-field-label gform-field-label--type-inline'>Painful light touch to skin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.27' type='checkbox'  value='Post surgical pain'  id='choice_5_158_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_27' id='label_5_158_27' class='gform-field-label gform-field-label--type-inline'>Post surgical pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_158_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.28' type='checkbox'  value='Other'  id='choice_5_158_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_158_28' id='label_5_158_28' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_159\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_159'>Pain with light touch of skin- Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_5_159' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Cold Upper Extremity(ies)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_160'><div class='gchoice gchoice_5_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='R'  id='choice_5_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_160_1' id='label_5_160_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='L'  id='choice_5_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_160_2' id='label_5_160_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_171\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Cold Lower Extremity(ies)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_171'><div class='gchoice gchoice_5_171_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_171.1' type='checkbox'  value='R'  id='choice_5_171_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_171_1' id='label_5_171_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_171_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_171.2' type='checkbox'  value='L'  id='choice_5_171_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_171_2' id='label_5_171_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_163\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_163'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_5_163' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_164\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >9. Cardiac<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_168'>\n\t\t\t<div class='gchoice gchoice_5_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='Yes'  id='choice_5_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_168_0' id='label_5_168_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='No Problems'  id='choice_5_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_168_1' id='label_5_168_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_166\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_166'><div class='gchoice gchoice_5_166_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.1' type='checkbox'  value='Heart Trouble'  id='choice_5_166_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_1' id='label_5_166_1' class='gform-field-label gform-field-label--type-inline'>Heart Trouble<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.2' type='checkbox'  value='Swelling of Feet'  id='choice_5_166_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_2' id='label_5_166_2' class='gform-field-label gform-field-label--type-inline'>Swelling of Feet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.3' type='checkbox'  value='High Blood Pressure'  id='choice_5_166_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_3' id='label_5_166_3' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.4' type='checkbox'  value='Chest Pain'  id='choice_5_166_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_4' id='label_5_166_4' class='gform-field-label gform-field-label--type-inline'>Chest Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.5' type='checkbox'  value='Heart Murmur'  id='choice_5_166_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_5' id='label_5_166_5' class='gform-field-label gform-field-label--type-inline'>Heart Murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.6' type='checkbox'  value='Heart Failure'  id='choice_5_166_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_6' id='label_5_166_6' class='gform-field-label gform-field-label--type-inline'>Heart Failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.7' type='checkbox'  value='Osteoporosis'  id='choice_5_166_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_7' id='label_5_166_7' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.8' type='checkbox'  value='Stents'  id='choice_5_166_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_8' id='label_5_166_8' class='gform-field-label gform-field-label--type-inline'>Stents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.9' type='checkbox'  value='Shortness of breath with walking'  id='choice_5_166_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_9' id='label_5_166_9' class='gform-field-label gform-field-label--type-inline'>Shortness of breath with walking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.11' type='checkbox'  value='Arterial Graft'  id='choice_5_166_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_11' id='label_5_166_11' class='gform-field-label gform-field-label--type-inline'>Arterial Graft<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.12' type='checkbox'  value='Pacemaker'  id='choice_5_166_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_12' id='label_5_166_12' class='gform-field-label gform-field-label--type-inline'>Pacemaker<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.13' type='checkbox'  value='Heart Disease'  id='choice_5_166_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_13' id='label_5_166_13' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.14' type='checkbox'  value='Edema'  id='choice_5_166_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_14' id='label_5_166_14' class='gform-field-label gform-field-label--type-inline'>Edema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.15' type='checkbox'  value='Palpitations'  id='choice_5_166_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_15' id='label_5_166_15' class='gform-field-label gform-field-label--type-inline'>Palpitations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.16' type='checkbox'  value='PND (Paroxysmal Nocturnal Dyspnea)'  id='choice_5_166_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_16' id='label_5_166_16' class='gform-field-label gform-field-label--type-inline'>PND (Paroxysmal Nocturnal Dyspnea)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.17' type='checkbox'  value='Blue Extremities'  id='choice_5_166_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_17' id='label_5_166_17' class='gform-field-label gform-field-label--type-inline'>Blue Extremities<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.18' type='checkbox'  value='Rheumatic Fever'  id='choice_5_166_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_18' id='label_5_166_18' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_166_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.19' type='checkbox'  value='Heart Attack or other Cardiac Condition'  id='choice_5_166_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_166_19' id='label_5_166_19' class='gform-field-label gform-field-label--type-inline'>Heart Attack or other Cardiac Condition<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_167\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_167'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_5_167' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_169\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_165\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >10. Peripheral-Vascular<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_165'>\n\t\t\t<div class='gchoice gchoice_5_165_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Yes'  id='choice_5_165_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_165_0' id='label_5_165_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_165_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='No Problems'  id='choice_5_165_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_165_1' id='label_5_165_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_181\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_181'><div class='gchoice gchoice_5_181_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Thrombophlebitis (Inflamed Veins)'  id='choice_5_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_1' id='label_5_181_1' class='gform-field-label gform-field-label--type-inline'>Thrombophlebitis (Inflamed Veins)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.2' type='checkbox'  value='Poor circulation in arms'  id='choice_5_181_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_2' id='label_5_181_2' class='gform-field-label gform-field-label--type-inline'>Poor circulation in arms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.3' type='checkbox'  value='Blood clots in arms'  id='choice_5_181_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_3' id='label_5_181_3' class='gform-field-label gform-field-label--type-inline'>Blood clots in arms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.4' type='checkbox'  value='Varicose Veins'  id='choice_5_181_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_4' id='label_5_181_4' class='gform-field-label gform-field-label--type-inline'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.5' type='checkbox'  value='Poor circulation in legs'  id='choice_5_181_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_5' id='label_5_181_5' class='gform-field-label gform-field-label--type-inline'>Poor circulation in legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.6' type='checkbox'  value='Blood clots in legs'  id='choice_5_181_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_6' id='label_5_181_6' class='gform-field-label gform-field-label--type-inline'>Blood clots in legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.7' type='checkbox'  value='Vascular Surgery'  id='choice_5_181_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_7' id='label_5_181_7' class='gform-field-label gform-field-label--type-inline'>Vascular Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_181_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.8' type='checkbox'  value='Other'  id='choice_5_181_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_181_8' id='label_5_181_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_172\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Poor circulation in arms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_172'><div class='gchoice gchoice_5_172_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.1' type='checkbox'  value='R'  id='choice_5_172_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_172_1' id='label_5_172_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_172_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.2' type='checkbox'  value='L'  id='choice_5_172_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_172_2' id='label_5_172_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_176\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Blood clots in arms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_176'><div class='gchoice gchoice_5_176_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_176.1' type='checkbox'  value='R'  id='choice_5_176_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_176_1' id='label_5_176_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_176_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_176.2' type='checkbox'  value='L'  id='choice_5_176_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_176_2' id='label_5_176_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_175\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Varicose Veins<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_175'><div class='gchoice gchoice_5_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='R'  id='choice_5_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_175_1' id='label_5_175_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_175_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.2' type='checkbox'  value='L'  id='choice_5_175_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_175_2' id='label_5_175_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_174\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Poor circulation in legs<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_174'><div class='gchoice gchoice_5_174_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.1' type='checkbox'  value='R'  id='choice_5_174_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_174_1' id='label_5_174_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_174_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.2' type='checkbox'  value='L'  id='choice_5_174_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_174_2' id='label_5_174_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_173\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Blood clots in legs<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_173'><div class='gchoice gchoice_5_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='R'  id='choice_5_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_173_1' id='label_5_173_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='L'  id='choice_5_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_173_2' id='label_5_173_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_177\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Vascular Surgery<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_177'><div class='gchoice gchoice_5_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='R'  id='choice_5_177_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_177_1' id='label_5_177_1' class='gform-field-label gform-field-label--type-inline'>R<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_177_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.2' type='checkbox'  value='L'  id='choice_5_177_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_177_2' id='label_5_177_2' class='gform-field-label gform-field-label--type-inline'>L<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_178\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_178'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_5_178' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_179\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_180\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >11. Gastrointestinal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_180'>\n\t\t\t<div class='gchoice gchoice_5_180_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='Yes'  id='choice_5_180_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_180_0' id='label_5_180_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_180_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_180' type='radio' value='No Problems'  id='choice_5_180_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_180_1' id='label_5_180_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_170\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_170'><div class='gchoice gchoice_5_170_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.1' type='checkbox'  value='IBS (Irritable Bowel Syndrome)'  id='choice_5_170_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_1' id='label_5_170_1' class='gform-field-label gform-field-label--type-inline'>IBS (Irritable Bowel Syndrome)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.2' type='checkbox'  value='Crohn&#039;s\/Ulcerative Cholitis'  id='choice_5_170_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_2' id='label_5_170_2' class='gform-field-label gform-field-label--type-inline'>Crohn's\/Ulcerative Cholitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.3' type='checkbox'  value='Constipation'  id='choice_5_170_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_3' id='label_5_170_3' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.4' type='checkbox'  value='Diarrhea'  id='choice_5_170_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_4' id='label_5_170_4' class='gform-field-label gform-field-label--type-inline'>Diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.5' type='checkbox'  value='Chronic use of laxatives'  id='choice_5_170_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_5' id='label_5_170_5' class='gform-field-label gform-field-label--type-inline'>Chronic use of laxatives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.6' type='checkbox'  value='Jaundice (Yellow Eyes)'  id='choice_5_170_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_6' id='label_5_170_6' class='gform-field-label gform-field-label--type-inline'>Jaundice (Yellow Eyes)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.7' type='checkbox'  value='Eating Disorder (Anorexia, Bulemia, etc)'  id='choice_5_170_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_7' id='label_5_170_7' class='gform-field-label gform-field-label--type-inline'>Eating Disorder (Anorexia, Bulemia, etc)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.8' type='checkbox'  value='Heartburn'  id='choice_5_170_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_8' id='label_5_170_8' class='gform-field-label gform-field-label--type-inline'>Heartburn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.9' type='checkbox'  value='Melena (Dark Stool)'  id='choice_5_170_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_9' id='label_5_170_9' class='gform-field-label gform-field-label--type-inline'>Melena (Dark Stool)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.11' type='checkbox'  value='Frequent Bowel Movements'  id='choice_5_170_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_11' id='label_5_170_11' class='gform-field-label gform-field-label--type-inline'>Frequent Bowel Movements<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.12' type='checkbox'  value='Change in Bowel Habits'  id='choice_5_170_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_12' id='label_5_170_12' class='gform-field-label gform-field-label--type-inline'>Change in Bowel Habits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.13' type='checkbox'  value='Clay Color Stool'  id='choice_5_170_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_13' id='label_5_170_13' class='gform-field-label gform-field-label--type-inline'>Clay Color Stool<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.14' type='checkbox'  value='Hemorrhoids'  id='choice_5_170_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_14' id='label_5_170_14' class='gform-field-label gform-field-label--type-inline'>Hemorrhoids<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.15' type='checkbox'  value='Rectal Discharge'  id='choice_5_170_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_15' id='label_5_170_15' class='gform-field-label gform-field-label--type-inline'>Rectal Discharge<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_170_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.16' type='checkbox'  value='Other'  id='choice_5_170_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_170_16' id='label_5_170_16' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_182\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_182'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_5_182' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_183\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_184\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >12. Endocrine<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_184'>\n\t\t\t<div class='gchoice gchoice_5_184_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='Yes'  id='choice_5_184_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_184_0' id='label_5_184_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_184_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='No Problems'  id='choice_5_184_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_184_1' id='label_5_184_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_185\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_185'><div class='gchoice gchoice_5_185_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.1' type='checkbox'  value='Diabetes'  id='choice_5_185_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_1' id='label_5_185_1' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.2' type='checkbox'  value='Hot\/Cold Tolerance'  id='choice_5_185_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_2' id='label_5_185_2' class='gform-field-label gform-field-label--type-inline'>Hot\/Cold Tolerance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.3' type='checkbox'  value='Excessive Sweating'  id='choice_5_185_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_3' id='label_5_185_3' class='gform-field-label gform-field-label--type-inline'>Excessive Sweating<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.4' type='checkbox'  value='Polydipsia (Increased Thirst)'  id='choice_5_185_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_4' id='label_5_185_4' class='gform-field-label gform-field-label--type-inline'>Polydipsia (Increased Thirst)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.5' type='checkbox'  value='Polyphagia (Increased Hunger)'  id='choice_5_185_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_5' id='label_5_185_5' class='gform-field-label gform-field-label--type-inline'>Polyphagia (Increased Hunger)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.6' type='checkbox'  value='Infertility'  id='choice_5_185_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_6' id='label_5_185_6' class='gform-field-label gform-field-label--type-inline'>Infertility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.7' type='checkbox'  value='Thyroid Disorder'  id='choice_5_185_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_7' id='label_5_185_7' class='gform-field-label gform-field-label--type-inline'>Thyroid Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_185_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.8' type='checkbox'  value='Other'  id='choice_5_185_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_185_8' id='label_5_185_8' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_186\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_186'>Please Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_5_186' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >Diabetes- If yes, do you take insulin<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_187'>\n\t\t\t<div class='gchoice gchoice_5_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='Yes'  id='choice_5_187_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_187_0' id='label_5_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_187_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='No'  id='choice_5_187_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_187_1' id='label_5_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_188\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_5col 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' >13. Respiratory<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_189'>\n\t\t\t<div class='gchoice gchoice_5_189_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='Yes'  id='choice_5_189_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_189_0' id='label_5_189_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_189_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_189' type='radio' value='No Problems'  id='choice_5_189_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_189_1' id='label_5_189_1' class='gform-field-label gform-field-label--type-inline'>No Problems<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_190\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col 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 gfield_label_before_complex' >Select all that apply<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_190'><div class='gchoice gchoice_5_190_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.1' type='checkbox'  value='Cough'  id='choice_5_190_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_1' id='label_5_190_1' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.2' type='checkbox'  value='Sputum'  id='choice_5_190_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_2' id='label_5_190_2' class='gform-field-label gform-field-label--type-inline'>Sputum<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.3' type='checkbox'  value='Hemoptysis (Coughing up blood)'  id='choice_5_190_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_3' id='label_5_190_3' class='gform-field-label gform-field-label--type-inline'>Hemoptysis (Coughing up blood)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.4' type='checkbox'  value='Wheezing'  id='choice_5_190_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_4' id='label_5_190_4' class='gform-field-label gform-field-label--type-inline'>Wheezing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.5' type='checkbox'  value='Asthma'  id='choice_5_190_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_5' id='label_5_190_5' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.6' type='checkbox'  value='Emphysema'  id='choice_5_190_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_6' id='label_5_190_6' class='gform-field-label gform-field-label--type-inline'>Emphysema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.7' type='checkbox'  value='Bronchitis'  id='choice_5_190_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_7' id='label_5_190_7' class='gform-field-label gform-field-label--type-inline'>Bronchitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.8' type='checkbox'  value='Pneumonia'  id='choice_5_190_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_8' id='label_5_190_8' class='gform-field-label gform-field-label--type-inline'>Pneumonia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.9' type='checkbox'  value='Pleurisy'  id='choice_5_190_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_9' id='label_5_190_9' class='gform-field-label gform-field-label--type-inline'>Pleurisy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.11' type='checkbox'  value='Sleep Apnea'  id='choice_5_190_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_11' id='label_5_190_11' class='gform-field-label gform-field-label--type-inline'>Sleep Apnea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.12' type='checkbox'  value='CPAP at night'  id='choice_5_190_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_12' id='label_5_190_12' class='gform-field-label gform-field-label--type-inline'>CPAP at night<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_190_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.13' type='checkbox'  value='COPD'  id='choice_5_190_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_190_13' id='label_5_190_13' class='gform-field-label gform-field-label--type-inline'>COPD<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_191\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_193\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_193'>14. Other<\/label><div class='gfield_description' id='gfield_description_5_193'>Please specify<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_193' id='input_5_193' class='textarea small'  aria-describedby=\"gfield_description_5_193\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_194' 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_5_194' 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_5_7' class='gform_page' data-js='page-field-id-194' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_195\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_195'>Treatment Goal(s):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_195' id='input_5_195' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_196\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Certification:<\/h3>\n<p>I certify that I have answered truthfully all the questions, and have not knowingly\n withheld any information concerning any of the above problems, either past or resent.<\/p><\/div><fieldset id=\"field_5_197\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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 gfield_label_before_complex' >Certification:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_197.1' id='input_5_197_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_197_1' >I certify that I have answered truthfully all the questions, and have not knowingly  withheld any information concerning any of the above problems, either past or resent.<\/label><input type='hidden' name='input_197.2' value='I certify that I have answered truthfully all the questions, and have not knowingly  withheld any information concerning any of the above problems, either past or resent.' class='gform_hidden' \/><input type='hidden' name='input_197.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_5_198\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_198'>Patient Signature: (Type your full name)<\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_5_198' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_199\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_199'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_199' id='input_5_199' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_5_199_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_199_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_199' class='gform_hidden' value='https:\/\/dreugenelipov.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_200\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_200'>Parent Signature if Minor:(Type your full name)<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_5_200' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_201\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_201'>Transcriber:<\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_5_201' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_202\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_202'>Reviewing Provider(s):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_202' id='input_5_202' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_5' 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_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_5' id='gform_theme_5' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_5' id='gform_style_settings_5' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_5' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='5' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' 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