{"id":519,"date":"2025-10-25T13:43:52","date_gmt":"2025-10-25T17:43:52","guid":{"rendered":"https:\/\/rmtandrac.com\/therapist\/?page_id=519"},"modified":"2025-11-16T11:55:40","modified_gmt":"2025-11-16T16:55:40","slug":"intake-initial-health-record","status":"publish","type":"page","link":"https:\/\/rmtandrac.com\/therapist\/intake-initial-health-record\/","title":{"rendered":"Initial Intake Form"},"content":{"rendered":"\n<h4 class=\"wp-block-heading has-vivid-cyan-blue-color has-text-color has-link-color wp-elements-835e3265191625e6b90f638c167fbce6\">Please fill your intake form as you visit first time<\/h4>\n\n\n<style id=\"wpforms-css-vars-594-block-b83e31e0-cb37-43d8-8e87-be6adec9a3a4\">\n\t\t\t\t#wpforms-594.wpforms-block-b83e31e0-cb37-43d8-8e87-be6adec9a3a4 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-b83e31e0-cb37-43d8-8e87-be6adec9a3a4 wpforms-render-modern\" id=\"wpforms-594\"><form id=\"wpforms-form-594\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"594\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/therapist\/wp-json\/wp\/v2\/pages\/519?wpforms_form_id=594\" data-token=\"50ec1ab6f4ac2055b2410c155c28c563\" data-token-time=\"1776621826\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-594-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Patient Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-594-field_0-error\" required><label for=\"wpforms-594-field_0\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-594-field_0-last-error\" required><label for=\"wpforms-594-field_0-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-594-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_1\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-594-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-594-field_1-error\" required><\/div><div id=\"wpforms-594-field_99-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"99\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_100-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_100\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-594-field_100\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][100][date]\" aria-errormessage=\"wpforms-594-field_100-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_11\">Sex <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-594-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><option value=\"Prefer not to say\"  class=\"choice-6 depth-1\"  >Prefer not to say<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_6-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_6\">Date of Intake <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-594-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-594-field_6-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_102-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"102\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_4\">Cell Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-594-field_4\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][4]\" aria-label=\"Cell Phone Number\" aria-errormessage=\"wpforms-594-field_4-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_9-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_9\">Home Phone Number<\/label><input type=\"tel\" id=\"wpforms-594-field_9\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][9]\" aria-label=\"Home Phone Number\" aria-errormessage=\"wpforms-594-field_9-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-594-field_10-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_10\">Work Phone<\/label><input type=\"tel\" id=\"wpforms-594-field_10\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][10]\" aria-label=\"Work Phone\" aria-errormessage=\"wpforms-594-field_10-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_3-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"3\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-594-field_3\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][3][address1]\" aria-errormessage=\"wpforms-594-field_3-error\" required><label for=\"wpforms-594-field_3\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-594-field_3-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][3][address2]\" aria-errormessage=\"wpforms-594-field_3-address2-error\" ><label for=\"wpforms-594-field_3-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-594-field_3-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][3][city]\" aria-errormessage=\"wpforms-594-field_3-city-error\" required><label for=\"wpforms-594-field_3-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_3-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][3][state]\" aria-errormessage=\"wpforms-594-field_3-state-error\" required><label for=\"wpforms-594-field_3-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-594-field_3-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][3][postal]\" aria-errormessage=\"wpforms-594-field_3-postal-error\" required><label for=\"wpforms-594-field_3-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-594-field_3-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][3][country]\" aria-errormessage=\"wpforms-594-field_3-country-error\" required><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-594-field_3-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-594-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_12\">Current or Previous Occupation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-594-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-594-field_12-error\" required><\/div><div id=\"wpforms-594-field_165-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"165\"><div id=\"wpforms-594-field_165\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_165-error\"><h4><span style=\"color:#0000ff\">EMERGENCY CONTACT INFORMATION<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-594-field_16-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Emergency Contact&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_16\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][16][first]\" aria-errormessage=\"wpforms-594-field_16-error\" required><label for=\"wpforms-594-field_16\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_16-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][16][last]\" aria-errormessage=\"wpforms-594-field_16-last-error\" required><label for=\"wpforms-594-field_16-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-594-field_17-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_17\">Contact Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-594-field_17\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][17]\" aria-label=\"Contact Number\" aria-errormessage=\"wpforms-594-field_17-error\" required><\/div><div id=\"wpforms-594-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_18\">Relation to Patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-594-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-594-field_18-error\" required><\/div><div id=\"wpforms-594-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_21\">Current Healthcare Provider Contact Information<\/label><input type=\"text\" id=\"wpforms-594-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-594-field_21-error\" aria-describedby=\"wpforms-594-field_21-description\" ><div id=\"wpforms-594-field_21-description\" class=\"wpforms-field-description\">Please add a contact phone number and email address<\/div><\/div><div id=\"wpforms-594-field_54-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Family Doctor&#039;s Name<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_54\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][54][first]\" aria-errormessage=\"wpforms-594-field_54-error\" ><label for=\"wpforms-594-field_54\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_54-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][54][last]\" aria-errormessage=\"wpforms-594-field_54-last-error\" ><label for=\"wpforms-594-field_54-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-594-field_56-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_56\">Family Doctor&#039;s Phone<\/label><input type=\"tel\" id=\"wpforms-594-field_56\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][56]\" aria-label=\"Family Doctor&#039;s Phone\" aria-errormessage=\"wpforms-594-field_56-error\" ><\/div><div id=\"wpforms-594-field_57-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"57\"><fieldset><legend class=\"wpforms-field-label\">Family Doctor&#039;s Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-594-field_57\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][57][address1]\" aria-errormessage=\"wpforms-594-field_57-error\" ><label for=\"wpforms-594-field_57\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-594-field_57-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][57][address2]\" aria-errormessage=\"wpforms-594-field_57-address2-error\" ><label for=\"wpforms-594-field_57-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-594-field_57-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][57][city]\" aria-errormessage=\"wpforms-594-field_57-city-error\" ><label for=\"wpforms-594-field_57-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-594-field_57-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][57][state]\" aria-errormessage=\"wpforms-594-field_57-state-error\" ><label for=\"wpforms-594-field_57-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-594-field_57-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][57][postal]\" aria-errormessage=\"wpforms-594-field_57-postal-error\" ><label for=\"wpforms-594-field_57-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-594-field_57-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][57][country]\" aria-errormessage=\"wpforms-594-field_57-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select country &#8212;<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-594-field_57-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-594-field_171-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"171\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_171\">Upload offline Intake form<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"171\"\n\t\tdata-form-id=\"594\"\n\t\tdata-input-name=\"wpforms_594_171\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heics,heif,heifs,asf,asx,wmv,wmx,wm,wma,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,ics,css,aac,flac,class,xcf,doc,docx,docm,onetoc,onetoc2,onepkg,odc,tsv,rtx,vtt,mp3,m4a,m4b,ra,ram,rar,wav,x-wav,ogg,oga,mid,midi,wax,mka,rtf,pdf,tar,zip,gz,gzip,7z,psd,pot,pps,ppt,potx,potm,ppsx,ppsm,pptx,pptm,wri,xla,xls,xlt,xlw,xlam,xlsx,xlsm,xlsb,xltx,xltm,mpp,dotx,dotm,ppam,sldx,sldm,oxps,xps,odt,odp,ods,odg,odb,odf,wp,wpd,key,numbers,pages,json\"\n\t\tdata-max-size=\"15380480\"\n\t\tdata-max-file-number=\"5\"\n\t\tdata-post-max-size=\"15380480\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 5 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-594-field_171\"\n\t\tname=\"wpforms_594_171\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-594-field_166-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"166\"><div id=\"wpforms-594-field_166\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_166-error\"><h4><span style=\"color:#0000ff\"><strong>CONDITIONS<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div>\t\t<div id=\"wpforms-594-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-594-field_2\" >Layout  Birth<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-594-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-594-field_162-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"162\"><fieldset><legend class=\"wpforms-field-label\">Do you have any conditions?<\/legend><ul id=\"wpforms-594-field_162\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_162_1\" name=\"wpforms[fields][162][]\" value=\"Yes\" aria-errormessage=\"wpforms-594-field_162_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_162_1\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_65-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"65\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Area of Complaint<\/legend><ul id=\"wpforms-594-field_65\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_1\" name=\"wpforms[fields][65][]\" value=\"Left Side of Neck\" aria-errormessage=\"wpforms-594-field_65_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_1\">Left Side of Neck<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_2\" name=\"wpforms[fields][65][]\" value=\"Right Side of Neck\" aria-errormessage=\"wpforms-594-field_65_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_2\">Right Side of Neck<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_3\" name=\"wpforms[fields][65][]\" value=\"Left Side of Upper Back\" aria-errormessage=\"wpforms-594-field_65_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_3\">Left Side of Upper Back<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_4\" name=\"wpforms[fields][65][]\" value=\"Right Side of Upper Back\" aria-errormessage=\"wpforms-594-field_65_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_4\">Right Side of Upper Back<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_5\" name=\"wpforms[fields][65][]\" value=\"Left Side of Mid Back\" aria-errormessage=\"wpforms-594-field_65_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_5\">Left Side of Mid Back<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_6\" name=\"wpforms[fields][65][]\" value=\"Right Side of Mid Back\" aria-errormessage=\"wpforms-594-field_65_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_6\">Right Side of Mid Back<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_7\" name=\"wpforms[fields][65][]\" value=\"Left Side of Low Back\" aria-errormessage=\"wpforms-594-field_65_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_7\">Left Side of Low Back<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_8\" name=\"wpforms[fields][65][]\" value=\"Right Side of Low Back\" aria-errormessage=\"wpforms-594-field_65_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_8\">Right Side of Low Back<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_9\" name=\"wpforms[fields][65][]\" value=\"Chest\" aria-errormessage=\"wpforms-594-field_65_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_9\">Chest<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_10\" name=\"wpforms[fields][65][]\" value=\"Abdomen\" aria-errormessage=\"wpforms-594-field_65_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_10\">Abdomen<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_11\" name=\"wpforms[fields][65][]\" value=\"Left Arm\" aria-errormessage=\"wpforms-594-field_65_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_11\">Left Arm<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_13\" name=\"wpforms[fields][65][]\" value=\"Right Arm\" aria-errormessage=\"wpforms-594-field_65_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_13\">Right Arm<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_14\" name=\"wpforms[fields][65][]\" value=\"Left Shoulder\" aria-errormessage=\"wpforms-594-field_65_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_14\">Left Shoulder<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_15\" name=\"wpforms[fields][65][]\" value=\"Right Shoulder\" aria-errormessage=\"wpforms-594-field_65_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_15\">Right Shoulder<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_16\" name=\"wpforms[fields][65][]\" value=\"Left Elbow\" aria-errormessage=\"wpforms-594-field_65_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_16\">Left Elbow<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_17\" name=\"wpforms[fields][65][]\" value=\"Right Elbow\" aria-errormessage=\"wpforms-594-field_65_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_17\">Right Elbow<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_18\" name=\"wpforms[fields][65][]\" value=\"Left Wrist\" aria-errormessage=\"wpforms-594-field_65_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_18\">Left Wrist<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_19\" name=\"wpforms[fields][65][]\" value=\"Right Wrist\" aria-errormessage=\"wpforms-594-field_65_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_19\">Right Wrist<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_20\" name=\"wpforms[fields][65][]\" value=\"Left Hand\" aria-errormessage=\"wpforms-594-field_65_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_20\">Left Hand<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_21\" name=\"wpforms[fields][65][]\" value=\"Right Hand\" aria-errormessage=\"wpforms-594-field_65_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_21\">Right Hand<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_23\" name=\"wpforms[fields][65][]\" value=\"Left Leg\" aria-errormessage=\"wpforms-594-field_65_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_23\">Left Leg<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_24\" name=\"wpforms[fields][65][]\" value=\"Right Leg\" aria-errormessage=\"wpforms-594-field_65_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_24\">Right Leg<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_25\" name=\"wpforms[fields][65][]\" value=\"Left Hip\" aria-errormessage=\"wpforms-594-field_65_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_25\">Left Hip<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_26\" name=\"wpforms[fields][65][]\" value=\"Right Hip\" aria-errormessage=\"wpforms-594-field_65_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_26\">Right Hip<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_27\" name=\"wpforms[fields][65][]\" value=\"Left Knee\" aria-errormessage=\"wpforms-594-field_65_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_27\">Left Knee<\/label><\/li><li class=\"choice-29 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_29\" name=\"wpforms[fields][65][]\" value=\"Right Knee\" aria-errormessage=\"wpforms-594-field_65_29-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_29\">Right Knee<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_30\" name=\"wpforms[fields][65][]\" value=\"Left Ankle\" aria-errormessage=\"wpforms-594-field_65_30-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_30\">Left Ankle<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_32\" name=\"wpforms[fields][65][]\" value=\"Left Foot\" aria-errormessage=\"wpforms-594-field_65_32-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_32\">Left Foot<\/label><\/li><li class=\"choice-33 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_65_33\" name=\"wpforms[fields][65][]\" value=\"Right Foot\" aria-errormessage=\"wpforms-594-field_65_33-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_65_33\">Right Foot<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_66-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Headaches<\/legend><ul id=\"wpforms-594-field_66\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_1\" name=\"wpforms[fields][66][]\" value=\"Migraines\" aria-errormessage=\"wpforms-594-field_66_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_1\">Migraines<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_2\" name=\"wpforms[fields][66][]\" value=\"Headaches\" aria-errormessage=\"wpforms-594-field_66_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_2\">Headaches<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_3\" name=\"wpforms[fields][66][]\" value=\"Cluster\" aria-errormessage=\"wpforms-594-field_66_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_3\">Cluster<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_4\" name=\"wpforms[fields][66][]\" value=\"Rebound\" aria-errormessage=\"wpforms-594-field_66_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_4\">Rebound<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_5\" name=\"wpforms[fields][66][]\" value=\"Sinus\" aria-errormessage=\"wpforms-594-field_66_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_5\">Sinus<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_7\" name=\"wpforms[fields][66][]\" value=\"Chronic Daily Headache\" aria-errormessage=\"wpforms-594-field_66_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_7\">Chronic Daily Headache<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_66_8\" name=\"wpforms[fields][66][]\" value=\"Tension\" aria-errormessage=\"wpforms-594-field_66_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_66_8\">Tension<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_67-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Neurological<\/legend><ul id=\"wpforms-594-field_67\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_1\" name=\"wpforms[fields][67][]\" value=\"Tingling\" aria-errormessage=\"wpforms-594-field_67_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_1\">Tingling<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_2\" name=\"wpforms[fields][67][]\" value=\"Multiple Sclerosis\" aria-errormessage=\"wpforms-594-field_67_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_2\">Multiple Sclerosis<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_3\" name=\"wpforms[fields][67][]\" value=\"Brain Injury\" aria-errormessage=\"wpforms-594-field_67_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_3\">Brain Injury<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_4\" name=\"wpforms[fields][67][]\" value=\"Stabbing\" aria-errormessage=\"wpforms-594-field_67_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_4\">Stabbing<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_5\" name=\"wpforms[fields][67][]\" value=\"Cerebral-vascular Accident\" aria-errormessage=\"wpforms-594-field_67_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_5\">Cerebral-vascular Accident<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_6\" name=\"wpforms[fields][67][]\" value=\"Cerebral Vascular Accident(Stroke)\" aria-errormessage=\"wpforms-594-field_67_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_6\">Cerebral Vascular Accident(Stroke)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_7\" name=\"wpforms[fields][67][]\" value=\"Sciatic Pain\" aria-errormessage=\"wpforms-594-field_67_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_7\">Sciatic Pain<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_8\" name=\"wpforms[fields][67][]\" value=\"Loss of Sensation\" aria-errormessage=\"wpforms-594-field_67_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_8\">Loss of Sensation<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_9\" name=\"wpforms[fields][67][]\" value=\"Seizure Disorder\" aria-errormessage=\"wpforms-594-field_67_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_9\">Seizure Disorder<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_10\" name=\"wpforms[fields][67][]\" value=\"Stroke\" aria-errormessage=\"wpforms-594-field_67_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_10\">Stroke<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_11\" name=\"wpforms[fields][67][]\" value=\"Transient Ischemic Attacks(TIA)\" aria-errormessage=\"wpforms-594-field_67_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_11\">Transient Ischemic Attacks(TIA)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_12\" name=\"wpforms[fields][67][]\" value=\"Vertebral and Spinal Cord Injury\" aria-errormessage=\"wpforms-594-field_67_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_12\">Vertebral and Spinal Cord Injury<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_13\" name=\"wpforms[fields][67][]\" value=\"Epilepsy\" aria-errormessage=\"wpforms-594-field_67_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_13\">Epilepsy<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_14\" name=\"wpforms[fields][67][]\" value=\"Shingles\" aria-errormessage=\"wpforms-594-field_67_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_14\">Shingles<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_16\" name=\"wpforms[fields][67][]\" value=\"Cerebral Palsy\" aria-errormessage=\"wpforms-594-field_67_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_16\">Cerebral Palsy<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_17\" name=\"wpforms[fields][67][]\" value=\"Huntington Disease\" aria-errormessage=\"wpforms-594-field_67_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_17\">Huntington Disease<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_18\" name=\"wpforms[fields][67][]\" value=\"Dizziness\" aria-errormessage=\"wpforms-594-field_67_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_18\">Dizziness<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_19\" name=\"wpforms[fields][67][]\" value=\"Parkinsons\" aria-errormessage=\"wpforms-594-field_67_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_19\">Parkinsons<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_20\" name=\"wpforms[fields][67][]\" value=\"Brain Disorder\" aria-errormessage=\"wpforms-594-field_67_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_20\">Brain Disorder<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_21\" name=\"wpforms[fields][67][]\" value=\"Numbness\" aria-errormessage=\"wpforms-594-field_67_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_21\">Numbness<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_22\" name=\"wpforms[fields][67][]\" value=\"Burning\" aria-errormessage=\"wpforms-594-field_67_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_22\">Burning<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_23\" name=\"wpforms[fields][67][]\" value=\"Herniated Disc\" aria-errormessage=\"wpforms-594-field_67_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_23\">Herniated Disc<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_67_24\" name=\"wpforms[fields][67][]\" value=\"Chronic Pain Disorder\" aria-errormessage=\"wpforms-594-field_67_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_67_24\">Chronic Pain Disorder<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_68-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Cardiovascular<\/legend><ul id=\"wpforms-594-field_68\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_1\" name=\"wpforms[fields][68][]\" value=\"Cardiovascular Conditions\" aria-errormessage=\"wpforms-594-field_68_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_1\">Cardiovascular Conditions<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_2\" name=\"wpforms[fields][68][]\" value=\"Congenital Heart Defect\" aria-errormessage=\"wpforms-594-field_68_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_2\">Congenital Heart Defect<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_3\" name=\"wpforms[fields][68][]\" value=\"Varicose Veins\" aria-errormessage=\"wpforms-594-field_68_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_3\">Varicose Veins<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_4\" name=\"wpforms[fields][68][]\" value=\"Heart Attack\" aria-errormessage=\"wpforms-594-field_68_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_4\">Heart Attack<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_5\" name=\"wpforms[fields][68][]\" value=\"Blood Pressure\" aria-errormessage=\"wpforms-594-field_68_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_5\">Blood Pressure<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_6\" name=\"wpforms[fields][68][]\" value=\"Acute Coronary Syndrome\" aria-errormessage=\"wpforms-594-field_68_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_6\">Acute Coronary Syndrome<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_8\" name=\"wpforms[fields][68][]\" value=\"Coronary Artery Disease\" aria-errormessage=\"wpforms-594-field_68_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_8\">Coronary Artery Disease<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_7\" name=\"wpforms[fields][68][]\" value=\"Blood Clots\" aria-errormessage=\"wpforms-594-field_68_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_7\">Blood Clots<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_9\" name=\"wpforms[fields][68][]\" value=\"Phlebitis\" aria-errormessage=\"wpforms-594-field_68_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_9\">Phlebitis<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_10\" name=\"wpforms[fields][68][]\" value=\"Aneurysm\" aria-errormessage=\"wpforms-594-field_68_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_10\">Aneurysm<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_11\" name=\"wpforms[fields][68][]\" value=\"Hyperlipidemia\" aria-errormessage=\"wpforms-594-field_68_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_11\">Hyperlipidemia<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_12\" name=\"wpforms[fields][68][]\" value=\"Lymphedema\" aria-errormessage=\"wpforms-594-field_68_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_12\">Lymphedema<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_13\" name=\"wpforms[fields][68][]\" value=\"Cardiovascular Accident\" aria-errormessage=\"wpforms-594-field_68_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_13\">Cardiovascular Accident<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_14\" name=\"wpforms[fields][68][]\" value=\"Angina\" aria-errormessage=\"wpforms-594-field_68_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_14\">Angina<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_15\" name=\"wpforms[fields][68][]\" value=\"Pericarditis\" aria-errormessage=\"wpforms-594-field_68_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_15\">Pericarditis<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_16\" name=\"wpforms[fields][68][]\" value=\"Pacemaker\" aria-errormessage=\"wpforms-594-field_68_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_16\">Pacemaker<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_17\" name=\"wpforms[fields][68][]\" value=\"Atherosclerosis\" aria-errormessage=\"wpforms-594-field_68_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_17\">Atherosclerosis<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_18\" name=\"wpforms[fields][68][]\" value=\"Raynaud Disease\" aria-errormessage=\"wpforms-594-field_68_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_18\">Raynaud Disease<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_19\" name=\"wpforms[fields][68][]\" value=\"Cold Hands\" aria-errormessage=\"wpforms-594-field_68_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_19\">Cold Hands<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_20\" name=\"wpforms[fields][68][]\" value=\"Heart Disease\" aria-errormessage=\"wpforms-594-field_68_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_20\">Heart Disease<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_21\" name=\"wpforms[fields][68][]\" value=\"Cardiac Arrhythmia\" aria-errormessage=\"wpforms-594-field_68_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_21\">Cardiac Arrhythmia<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_22\" name=\"wpforms[fields][68][]\" value=\"Rheumatic Heart Disease\" aria-errormessage=\"wpforms-594-field_68_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_22\">Rheumatic Heart Disease<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_23\" name=\"wpforms[fields][68][]\" value=\"High Blood Pressure\" aria-errormessage=\"wpforms-594-field_68_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_23\">High Blood Pressure<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_24\" name=\"wpforms[fields][68][]\" value=\"Cold Feet\" aria-errormessage=\"wpforms-594-field_68_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_24\">Cold Feet<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_25\" name=\"wpforms[fields][68][]\" value=\"Chronic Ischemic Heart Disease\" aria-errormessage=\"wpforms-594-field_68_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_25\">Chronic Ischemic Heart Disease<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_27\" name=\"wpforms[fields][68][]\" value=\"Valve Disorder\" aria-errormessage=\"wpforms-594-field_68_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_27\">Valve Disorder<\/label><\/li><li class=\"choice-28 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_28\" name=\"wpforms[fields][68][]\" value=\"Low Blood Pressure\" aria-errormessage=\"wpforms-594-field_68_28-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_28\">Low Blood Pressure<\/label><\/li><li class=\"choice-30 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_30\" name=\"wpforms[fields][68][]\" value=\"Chronic Venous Insufficiency\" aria-errormessage=\"wpforms-594-field_68_30-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_30\">Chronic Venous Insufficiency<\/label><\/li><li class=\"choice-31 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_31\" name=\"wpforms[fields][68][]\" value=\"Myocardial infarction\" aria-errormessage=\"wpforms-594-field_68_31-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_31\">Myocardial infarction<\/label><\/li><li class=\"choice-32 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_68_32\" name=\"wpforms[fields][68][]\" value=\"Congestive Heart Failure\" aria-errormessage=\"wpforms-594-field_68_32-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_68_32\">Congestive Heart Failure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_69-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"69\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Reproductive<\/legend><ul id=\"wpforms-594-field_69\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_1\" name=\"wpforms[fields][69][]\" value=\"Menstrual Cycle Disorder\" aria-errormessage=\"wpforms-594-field_69_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_1\">Menstrual Cycle Disorder<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_2\" name=\"wpforms[fields][69][]\" value=\"Ovarian Cysts\/ Tumors\" aria-errormessage=\"wpforms-594-field_69_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_2\">Ovarian Cysts\/ Tumors<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_4\" name=\"wpforms[fields][69][]\" value=\"Pelvic Inflammatory Disease\" aria-errormessage=\"wpforms-594-field_69_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_4\">Pelvic Inflammatory Disease<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_5\" name=\"wpforms[fields][69][]\" value=\"Premenstrual Syndrome\" aria-errormessage=\"wpforms-594-field_69_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_5\">Premenstrual Syndrome<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_6\" name=\"wpforms[fields][69][]\" value=\"Pregnancy\" aria-errormessage=\"wpforms-594-field_69_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_6\">Pregnancy<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_7\" name=\"wpforms[fields][69][]\" value=\"Uterine Disorder\" aria-errormessage=\"wpforms-594-field_69_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_7\">Uterine Disorder<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_9\" name=\"wpforms[fields][69][]\" value=\"Gynaecological Conditions\" aria-errormessage=\"wpforms-594-field_69_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_9\">Gynaecological Conditions<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_10\" name=\"wpforms[fields][69][]\" value=\"Breast Disorder\" aria-errormessage=\"wpforms-594-field_69_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_10\">Breast Disorder<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_11\" name=\"wpforms[fields][69][]\" value=\"Ectopic Pregnancy\" aria-errormessage=\"wpforms-594-field_69_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_11\">Ectopic Pregnancy<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_12\" name=\"wpforms[fields][69][]\" value=\"Endometriosis\" aria-errormessage=\"wpforms-594-field_69_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_12\">Endometriosis<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_69_13\" name=\"wpforms[fields][69][]\" value=\"Menopause\" aria-errormessage=\"wpforms-594-field_69_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_69_13\">Menopause<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_70-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Immune<\/legend><ul id=\"wpforms-594-field_70\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_1\" name=\"wpforms[fields][70][]\" value=\"Non-Hodgkin Lymphoma\" aria-errormessage=\"wpforms-594-field_70_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_1\">Non-Hodgkin Lymphoma<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_2\" name=\"wpforms[fields][70][]\" value=\"Rheumatoid Arthritis\" aria-errormessage=\"wpforms-594-field_70_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_2\">Rheumatoid Arthritis<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_3\" name=\"wpforms[fields][70][]\" value=\"Anaphylaxis\" aria-errormessage=\"wpforms-594-field_70_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_3\">Anaphylaxis<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_4\" name=\"wpforms[fields][70][]\" value=\"Allergies\" aria-errormessage=\"wpforms-594-field_70_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_4\">Allergies<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_5\" name=\"wpforms[fields][70][]\" value=\"Lupus\" aria-errormessage=\"wpforms-594-field_70_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_5\">Lupus<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_6\" name=\"wpforms[fields][70][]\" value=\"Hodgkin Lymphoma\" aria-errormessage=\"wpforms-594-field_70_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_6\">Hodgkin Lymphoma<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_7\" name=\"wpforms[fields][70][]\" value=\"Infectious Mononucleosis\" aria-errormessage=\"wpforms-594-field_70_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_7\">Infectious Mononucleosis<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_8\" name=\"wpforms[fields][70][]\" value=\"Cancer\" aria-errormessage=\"wpforms-594-field_70_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_8\">Cancer<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_70_9\" name=\"wpforms[fields][70][]\" value=\"Leukemia\" aria-errormessage=\"wpforms-594-field_70_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_70_9\">Leukemia<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_71-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Musculoskeletal<\/legend><ul id=\"wpforms-594-field_71\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_1\" name=\"wpforms[fields][71][]\" value=\"Hereditary\/Congenitial Deformity\" aria-errormessage=\"wpforms-594-field_71_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_1\">Hereditary\/Congenitial Deformity<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_2\" name=\"wpforms[fields][71][]\" value=\"Strain\/Sprain\" aria-errormessage=\"wpforms-594-field_71_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_2\">Strain\/Sprain<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_3\" name=\"wpforms[fields][71][]\" value=\"Joint Injury\" aria-errormessage=\"wpforms-594-field_71_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_3\">Joint Injury<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_4\" name=\"wpforms[fields][71][]\" value=\"Amyotrophic Lateral Sclerosis (ALS)\" aria-errormessage=\"wpforms-594-field_71_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_4\">Amyotrophic Lateral Sclerosis (ALS)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_5\" name=\"wpforms[fields][71][]\" value=\"Osgood-Schlatter Disease\" aria-errormessage=\"wpforms-594-field_71_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_5\">Osgood-Schlatter Disease<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_6\" name=\"wpforms[fields][71][]\" value=\"Osteoporosis\" aria-errormessage=\"wpforms-594-field_71_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_6\">Osteoporosis<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_7\" name=\"wpforms[fields][71][]\" value=\"Muscular Dystropy\" aria-errormessage=\"wpforms-594-field_71_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_7\">Muscular Dystropy<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_8\" name=\"wpforms[fields][71][]\" value=\"Osteoarthritis\" aria-errormessage=\"wpforms-594-field_71_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_8\">Osteoarthritis<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_9\" name=\"wpforms[fields][71][]\" value=\"Ankylosing Spondylitis\" aria-errormessage=\"wpforms-594-field_71_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_9\">Ankylosing Spondylitis<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_10\" name=\"wpforms[fields][71][]\" value=\"Gout\" aria-errormessage=\"wpforms-594-field_71_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_10\">Gout<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_11\" name=\"wpforms[fields][71][]\" value=\"Osteomalacia\" aria-errormessage=\"wpforms-594-field_71_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_11\">Osteomalacia<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_12\" name=\"wpforms[fields][71][]\" value=\"Myasthenia Gravis\" aria-errormessage=\"wpforms-594-field_71_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_12\">Myasthenia Gravis<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_13\" name=\"wpforms[fields][71][]\" value=\"Tendonitis\/Bursitis\" aria-errormessage=\"wpforms-594-field_71_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_13\">Tendonitis\/Bursitis<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_14\" name=\"wpforms[fields][71][]\" value=\"Bone Disease\" aria-errormessage=\"wpforms-594-field_71_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_14\">Bone Disease<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_15\" name=\"wpforms[fields][71][]\" value=\"Paget Disease\" aria-errormessage=\"wpforms-594-field_71_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_15\">Paget Disease<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_16\" name=\"wpforms[fields][71][]\" value=\"Sinus Problems\" aria-errormessage=\"wpforms-594-field_71_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_16\">Sinus Problems<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_17\" name=\"wpforms[fields][71][]\" value=\"Compartment Syndrome\" aria-errormessage=\"wpforms-594-field_71_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_17\">Compartment Syndrome<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_18\" name=\"wpforms[fields][71][]\" value=\"Psoriatic Arthritis\" aria-errormessage=\"wpforms-594-field_71_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_18\">Psoriatic Arthritis<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_19\" name=\"wpforms[fields][71][]\" value=\"Artificial Joints\/ Special Equipment\" aria-errormessage=\"wpforms-594-field_71_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_19\">Artificial Joints\/ Special Equipment<\/label><\/li><li class=\"choice-21 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_21\" name=\"wpforms[fields][71][]\" value=\"Dislocation\" aria-errormessage=\"wpforms-594-field_71_21-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_21\">Dislocation<\/label><\/li><li class=\"choice-22 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_22\" name=\"wpforms[fields][71][]\" value=\"Scleroderma\" aria-errormessage=\"wpforms-594-field_71_22-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_22\">Scleroderma<\/label><\/li><li class=\"choice-23 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_23\" name=\"wpforms[fields][71][]\" value=\"Fibromyalgia\" aria-errormessage=\"wpforms-594-field_71_23-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_23\">Fibromyalgia<\/label><\/li><li class=\"choice-25 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_25\" name=\"wpforms[fields][71][]\" value=\"Fracture\" aria-errormessage=\"wpforms-594-field_71_25-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_25\">Fracture<\/label><\/li><li class=\"choice-24 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_24\" name=\"wpforms[fields][71][]\" value=\"Arthritis\" aria-errormessage=\"wpforms-594-field_71_24-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_24\">Arthritis<\/label><\/li><li class=\"choice-26 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_26\" name=\"wpforms[fields][71][]\" value=\"Jaw Pain(TMJD)\" aria-errormessage=\"wpforms-594-field_71_26-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_26\">Jaw Pain(TMJD)<\/label><\/li><li class=\"choice-27 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_71_27\" name=\"wpforms[fields][71][]\" value=\"Scoliosis\" aria-errormessage=\"wpforms-594-field_71_27-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_71_27\">Scoliosis<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_72-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Gastrointestinal <\/legend><ul id=\"wpforms-594-field_72\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_1\" name=\"wpforms[fields][72][]\" value=\"Constipation\" aria-errormessage=\"wpforms-594-field_72_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_1\">Constipation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_2\" name=\"wpforms[fields][72][]\" value=\"Digestive Conditions\" aria-errormessage=\"wpforms-594-field_72_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_2\">Digestive Conditions<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_3\" name=\"wpforms[fields][72][]\" value=\"Poor Appetite\" aria-errormessage=\"wpforms-594-field_72_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_3\">Poor Appetite<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_4\" name=\"wpforms[fields][72][]\" value=\"Diarrhea\" aria-errormessage=\"wpforms-594-field_72_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_4\">Diarrhea<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_5\" name=\"wpforms[fields][72][]\" value=\"Stomach Disorder\" aria-errormessage=\"wpforms-594-field_72_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_5\">Stomach Disorder<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_6\" name=\"wpforms[fields][72][]\" value=\"Crohn&#039;s Disease\" aria-errormessage=\"wpforms-594-field_72_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_6\">Crohn&#8217;s Disease<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_7\" name=\"wpforms[fields][72][]\" value=\"Diverticulitis\" aria-errormessage=\"wpforms-594-field_72_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_7\">Diverticulitis<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_8\" name=\"wpforms[fields][72][]\" value=\"Ulcerative Colitis\" aria-errormessage=\"wpforms-594-field_72_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_8\">Ulcerative Colitis<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_9\" name=\"wpforms[fields][72][]\" value=\"Eating Disorder\" aria-errormessage=\"wpforms-594-field_72_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_9\">Eating Disorder<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_10\" name=\"wpforms[fields][72][]\" value=\"Esophageal Disorder\" aria-errormessage=\"wpforms-594-field_72_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_10\">Esophageal Disorder<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_11\" name=\"wpforms[fields][72][]\" value=\"Fecal Impaction\" aria-errormessage=\"wpforms-594-field_72_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_11\">Fecal Impaction<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_12\" name=\"wpforms[fields][72][]\" value=\"Intestinal Polyps\" aria-errormessage=\"wpforms-594-field_72_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_12\">Intestinal Polyps<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_13\" name=\"wpforms[fields][72][]\" value=\"Celiac Disease\" aria-errormessage=\"wpforms-594-field_72_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_13\">Celiac Disease<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_72_15\" name=\"wpforms[fields][72][]\" value=\"Irritable Bowel Syndrome\" aria-errormessage=\"wpforms-594-field_72_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_72_15\">Irritable Bowel Syndrome<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_73-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Blood<\/legend><ul id=\"wpforms-594-field_73\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_1\" name=\"wpforms[fields][73][]\" value=\"Hyper coagulability\" aria-errormessage=\"wpforms-594-field_73_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_1\">Hyper coagulability<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_2\" name=\"wpforms[fields][73][]\" value=\"Hepatities\" aria-errormessage=\"wpforms-594-field_73_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_2\">Hepatities<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_4\" name=\"wpforms[fields][73][]\" value=\"Polycythemia\" aria-errormessage=\"wpforms-594-field_73_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_4\">Polycythemia<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_6\" name=\"wpforms[fields][73][]\" value=\"Haemophilia\" aria-errormessage=\"wpforms-594-field_73_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_6\">Haemophilia<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_7\" name=\"wpforms[fields][73][]\" value=\"HIV\" aria-errormessage=\"wpforms-594-field_73_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_7\">HIV<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_8\" name=\"wpforms[fields][73][]\" value=\"Thrombosis\/Embolism\" aria-errormessage=\"wpforms-594-field_73_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_8\">Thrombosis\/Embolism<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_9\" name=\"wpforms[fields][73][]\" value=\"High Cholesterol\" aria-errormessage=\"wpforms-594-field_73_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_9\">High Cholesterol<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_10\" name=\"wpforms[fields][73][]\" value=\"Anemia\" aria-errormessage=\"wpforms-594-field_73_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_10\">Anemia<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_11\" name=\"wpforms[fields][73][]\" value=\"Bleeding Disorder\" aria-errormessage=\"wpforms-594-field_73_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_11\">Bleeding Disorder<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_73_12\" name=\"wpforms[fields][73][]\" value=\"HIV\/AIDS\" aria-errormessage=\"wpforms-594-field_73_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_73_12\">HIV\/AIDS<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_74-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Skin<\/legend><ul id=\"wpforms-594-field_74\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_1\" name=\"wpforms[fields][74][]\" value=\"Acne\" aria-errormessage=\"wpforms-594-field_74_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_1\">Acne<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_2\" name=\"wpforms[fields][74][]\" value=\"Athlete&#039;s Foot\" aria-errormessage=\"wpforms-594-field_74_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_2\">Athlete&#8217;s Foot<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_3\" name=\"wpforms[fields][74][]\" value=\"Psoriasis\" aria-errormessage=\"wpforms-594-field_74_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_3\">Psoriasis<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_4\" name=\"wpforms[fields][74][]\" value=\"Allergic Dermatosis\" aria-errormessage=\"wpforms-594-field_74_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_4\">Allergic Dermatosis<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_5\" name=\"wpforms[fields][74][]\" value=\"Rash\" aria-errormessage=\"wpforms-594-field_74_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_5\">Rash<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_6\" name=\"wpforms[fields][74][]\" value=\"Bruise Easily\" aria-errormessage=\"wpforms-594-field_74_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_6\">Bruise Easily<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_7\" name=\"wpforms[fields][74][]\" value=\"Athletes Foot\" aria-errormessage=\"wpforms-594-field_74_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_7\">Athletes Foot<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_8\" name=\"wpforms[fields][74][]\" value=\"Herpes\" aria-errormessage=\"wpforms-594-field_74_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_8\">Herpes<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_9\" name=\"wpforms[fields][74][]\" value=\"Hypersensitive Reaction\" aria-errormessage=\"wpforms-594-field_74_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_9\">Hypersensitive Reaction<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_10\" name=\"wpforms[fields][74][]\" value=\"Rosacea\" aria-errormessage=\"wpforms-594-field_74_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_10\">Rosacea<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_11\" name=\"wpforms[fields][74][]\" value=\"Chemical Burn\" aria-errormessage=\"wpforms-594-field_74_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_11\">Chemical Burn<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_12\" name=\"wpforms[fields][74][]\" value=\"UV Burn\" aria-errormessage=\"wpforms-594-field_74_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_12\">UV Burn<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_13\" name=\"wpforms[fields][74][]\" value=\"Hypersensitive Reactions\" aria-errormessage=\"wpforms-594-field_74_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_13\">Hypersensitive Reactions<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_14\" name=\"wpforms[fields][74][]\" value=\"Melanoma\" aria-errormessage=\"wpforms-594-field_74_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_14\">Melanoma<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_15\" name=\"wpforms[fields][74][]\" value=\"Melanoma\/Carcinoma\" aria-errormessage=\"wpforms-594-field_74_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_15\">Melanoma\/Carcinoma<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_16\" name=\"wpforms[fields][74][]\" value=\"Skin Conditions\" aria-errormessage=\"wpforms-594-field_74_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_16\">Skin Conditions<\/label><\/li><li class=\"choice-17 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_17\" name=\"wpforms[fields][74][]\" value=\"Infectious Skin Conditions\" aria-errormessage=\"wpforms-594-field_74_17-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_17\">Infectious Skin Conditions<\/label><\/li><li class=\"choice-18 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_18\" name=\"wpforms[fields][74][]\" value=\"Pigmentary Disorder\" aria-errormessage=\"wpforms-594-field_74_18-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_18\">Pigmentary Disorder<\/label><\/li><li class=\"choice-19 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_19\" name=\"wpforms[fields][74][]\" value=\"Skin Irritations\" aria-errormessage=\"wpforms-594-field_74_19-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_19\">Skin Irritations<\/label><\/li><li class=\"choice-20 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_74_20\" name=\"wpforms[fields][74][]\" value=\"Plantar&#039;s Wart\" aria-errormessage=\"wpforms-594-field_74_20-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_74_20\">Plantar&#8217;s Wart<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_75-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Respiratory<\/legend><ul id=\"wpforms-594-field_75\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_1\" name=\"wpforms[fields][75][]\" value=\"Chronic Cough\" aria-errormessage=\"wpforms-594-field_75_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_1\">Chronic Cough<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_2\" name=\"wpforms[fields][75][]\" value=\"Respiratory Conditions\" aria-errormessage=\"wpforms-594-field_75_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_2\">Respiratory Conditions<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_3\" name=\"wpforms[fields][75][]\" value=\"Shortness of Breath\" aria-errormessage=\"wpforms-594-field_75_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_3\">Shortness of Breath<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_5\" name=\"wpforms[fields][75][]\" value=\"Asthma\" aria-errormessage=\"wpforms-594-field_75_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_5\">Asthma<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_4\" name=\"wpforms[fields][75][]\" value=\"Tuberculosis\" aria-errormessage=\"wpforms-594-field_75_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_4\">Tuberculosis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_6\" name=\"wpforms[fields][75][]\" value=\"Emphysema\" aria-errormessage=\"wpforms-594-field_75_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_6\">Emphysema<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_7\" name=\"wpforms[fields][75][]\" value=\"Bronchities\" aria-errormessage=\"wpforms-594-field_75_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_7\">Bronchities<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_8\" name=\"wpforms[fields][75][]\" value=\"Respiratory Tract Infection\" aria-errormessage=\"wpforms-594-field_75_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_8\">Respiratory Tract Infection<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_9\" name=\"wpforms[fields][75][]\" value=\"COPD\" aria-errormessage=\"wpforms-594-field_75_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_9\">COPD<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_10\" name=\"wpforms[fields][75][]\" value=\"Cystic Fibrosis\" aria-errormessage=\"wpforms-594-field_75_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_10\">Cystic Fibrosis<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_75_12\" name=\"wpforms[fields][75][]\" value=\"Infectious Respiratory Conditions\" aria-errormessage=\"wpforms-594-field_75_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_75_12\">Infectious Respiratory Conditions<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_76-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Hearing<\/legend><ul id=\"wpforms-594-field_76\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_1\" name=\"wpforms[fields][76][]\" value=\"Conductive Hearing Loss\" aria-errormessage=\"wpforms-594-field_76_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_1\">Conductive Hearing Loss<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_2\" name=\"wpforms[fields][76][]\" value=\"Meniere Disease\" aria-errormessage=\"wpforms-594-field_76_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_2\">Meniere Disease<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_3\" name=\"wpforms[fields][76][]\" value=\"Motion Sickness\" aria-errormessage=\"wpforms-594-field_76_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_3\">Motion Sickness<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_4\" name=\"wpforms[fields][76][]\" value=\"Tinnitus\" aria-errormessage=\"wpforms-594-field_76_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_4\">Tinnitus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_5\" name=\"wpforms[fields][76][]\" value=\"Ear Problems\" aria-errormessage=\"wpforms-594-field_76_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_5\">Ear Problems<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_6\" name=\"wpforms[fields][76][]\" value=\"Vertigo\" aria-errormessage=\"wpforms-594-field_76_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_6\">Vertigo<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_76_7\" name=\"wpforms[fields][76][]\" value=\"Hearing Loss\" aria-errormessage=\"wpforms-594-field_76_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_76_7\">Hearing Loss<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_77-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Kidney<\/legend><ul id=\"wpforms-594-field_77\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_1\" name=\"wpforms[fields][77][]\" value=\"Renal Cysts\" aria-errormessage=\"wpforms-594-field_77_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_1\">Renal Cysts<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_2\" name=\"wpforms[fields][77][]\" value=\"Urinary Incontinence\" aria-errormessage=\"wpforms-594-field_77_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_2\">Urinary Incontinence<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_3\" name=\"wpforms[fields][77][]\" value=\"Urinary Tract Infection\" aria-errormessage=\"wpforms-594-field_77_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_3\">Urinary Tract Infection<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_4\" name=\"wpforms[fields][77][]\" value=\"Bladder Disorder\" aria-errormessage=\"wpforms-594-field_77_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_4\">Bladder Disorder<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_5\" name=\"wpforms[fields][77][]\" value=\"Chronic Kidney Disease\" aria-errormessage=\"wpforms-594-field_77_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_5\">Chronic Kidney Disease<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_6\" name=\"wpforms[fields][77][]\" value=\"Congenital Kidney Disease\" aria-errormessage=\"wpforms-594-field_77_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_6\">Congenital Kidney Disease<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_7\" name=\"wpforms[fields][77][]\" value=\"Electrolyte Imbalance\" aria-errormessage=\"wpforms-594-field_77_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_7\">Electrolyte Imbalance<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_77_8\" name=\"wpforms[fields][77][]\" value=\"Kidney Stones\" aria-errormessage=\"wpforms-594-field_77_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_77_8\">Kidney Stones<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_78-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"78\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Endocrine<\/legend><ul id=\"wpforms-594-field_78\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_78_1\" name=\"wpforms[fields][78][]\" value=\"Acute Pancreatitis\" aria-errormessage=\"wpforms-594-field_78_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_78_1\">Acute Pancreatitis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_78_2\" name=\"wpforms[fields][78][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-594-field_78_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_78_2\">Diabetes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_78_3\" name=\"wpforms[fields][78][]\" value=\"Hyperthyroidism\" aria-errormessage=\"wpforms-594-field_78_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_78_3\">Hyperthyroidism<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_78_4\" name=\"wpforms[fields][78][]\" value=\"Pituitary and Growth Disorder\" aria-errormessage=\"wpforms-594-field_78_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_78_4\">Pituitary and Growth Disorder<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_78_5\" name=\"wpforms[fields][78][]\" value=\"Prostate Condition\" aria-errormessage=\"wpforms-594-field_78_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_78_5\">Prostate Condition<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_79-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"79\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Family History<\/legend><ul id=\"wpforms-594-field_79\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_79_1\" name=\"wpforms[fields][79][]\" value=\"Arthritis\" aria-errormessage=\"wpforms-594-field_79_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_79_1\">Arthritis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_79_2\" name=\"wpforms[fields][79][]\" value=\"Cardiovascular\" aria-errormessage=\"wpforms-594-field_79_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_79_2\">Cardiovascular<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_79_3\" name=\"wpforms[fields][79][]\" value=\"Respiratory\" aria-errormessage=\"wpforms-594-field_79_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_79_3\">Respiratory<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_80-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"80\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Miscellaneous<\/legend><ul id=\"wpforms-594-field_80\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_1\" name=\"wpforms[fields][80][]\" value=\"Vision Problems\" aria-errormessage=\"wpforms-594-field_80_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_1\">Vision Problems<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_2\" name=\"wpforms[fields][80][]\" value=\"Vision Loss\" aria-errormessage=\"wpforms-594-field_80_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_2\">Vision Loss<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_3\" name=\"wpforms[fields][80][]\" value=\"Mental Health Issues\" aria-errormessage=\"wpforms-594-field_80_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_3\">Mental Health Issues<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_4\" name=\"wpforms[fields][80][]\" value=\"Surgical Pins or Wire\" aria-errormessage=\"wpforms-594-field_80_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_4\">Surgical Pins or Wire<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_5\" name=\"wpforms[fields][80][]\" value=\"Insomnia\" aria-errormessage=\"wpforms-594-field_80_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_5\">Insomnia<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_6\" name=\"wpforms[fields][80][]\" value=\"Other Medical Conditions\" aria-errormessage=\"wpforms-594-field_80_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_6\">Other Medical Conditions<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_80_7\" name=\"wpforms[fields][80][]\" value=\"Other Diagnosed Diseases\" aria-errormessage=\"wpforms-594-field_80_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_80_7\">Other Diagnosed Diseases<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_167-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"167\"><div id=\"wpforms-594-field_167\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_167-error\"><h4><span style=\"color:#0000ff\"><strong>MEDICATIONS<\/strong><\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-594-field_104-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_104\">How many medications do you have now?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-594-field_104\" class=\"wpforms-field-medium\" name=\"wpforms[fields][104]\" value=\"0\" aria-errormessage=\"wpforms-594-field_104-error\"\t\tmin=\"0\"\n\tmax=\"8\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-594-field_105-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"105\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_106-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"106\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_106\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_106\" class=\"wpforms-field-medium\" name=\"wpforms[fields][106]\" aria-errormessage=\"wpforms-594-field_106-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_107-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_107\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_107\" class=\"wpforms-field-medium\" name=\"wpforms[fields][107]\" aria-errormessage=\"wpforms-594-field_107-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_108-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_108\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_108\" class=\"wpforms-field-medium\" name=\"wpforms[fields][108]\" aria-errormessage=\"wpforms-594-field_108-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_109-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_109\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_109\" class=\"wpforms-field-medium\" name=\"wpforms[fields][109]\" aria-errormessage=\"wpforms-594-field_109-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_110-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"110\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_110\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_110\" class=\"wpforms-field-medium\" name=\"wpforms[fields][110]\" aria-errormessage=\"wpforms-594-field_110-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_111-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"111\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_111\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_111\" class=\"wpforms-field-medium\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-594-field_111-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_112-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"112\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_112\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_112\" class=\"wpforms-field-medium\" name=\"wpforms[fields][112]\" aria-errormessage=\"wpforms-594-field_112-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_113-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"113\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_113\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_113\" class=\"wpforms-field-medium\" name=\"wpforms[fields][113]\" aria-errormessage=\"wpforms-594-field_113-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_114-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"114\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_114\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_114\" class=\"wpforms-field-medium\" name=\"wpforms[fields][114]\" aria-errormessage=\"wpforms-594-field_114-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_115-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"115\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_115\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_115\" class=\"wpforms-field-medium\" name=\"wpforms[fields][115]\" aria-errormessage=\"wpforms-594-field_115-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_116-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"116\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_116\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_116\" class=\"wpforms-field-medium\" name=\"wpforms[fields][116]\" aria-errormessage=\"wpforms-594-field_116-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_117-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"117\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_117\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_117\" class=\"wpforms-field-medium\" name=\"wpforms[fields][117]\" aria-errormessage=\"wpforms-594-field_117-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_118-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"118\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_118\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_118\" class=\"wpforms-field-medium\" name=\"wpforms[fields][118]\" aria-errormessage=\"wpforms-594-field_118-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_119-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"119\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_119\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_119\" class=\"wpforms-field-medium\" name=\"wpforms[fields][119]\" aria-errormessage=\"wpforms-594-field_119-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_120-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"120\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_120\">Medication<\/label><input type=\"text\" id=\"wpforms-594-field_120\" class=\"wpforms-field-medium\" name=\"wpforms[fields][120]\" aria-errormessage=\"wpforms-594-field_120-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_121-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"121\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_121\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_121\" class=\"wpforms-field-medium\" name=\"wpforms[fields][121]\" aria-errormessage=\"wpforms-594-field_121-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_168-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"168\"><div id=\"wpforms-594-field_168\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_168-error\"><h4><span style=\"color:#0000ff\">INJURIES<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-594-field_123-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"123\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_123\">How many times have you been injured?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-594-field_123\" class=\"wpforms-field-medium\" name=\"wpforms[fields][123]\" value=\"0\" aria-errormessage=\"wpforms-594-field_123-error\"\t\tmin=\"0\"\n\tmax=\"8\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-594-field_124-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"124\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_125-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"125\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_125\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_125\" class=\"wpforms-field-medium\" name=\"wpforms[fields][125]\" aria-errormessage=\"wpforms-594-field_125-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_126-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"126\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_126\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_126\" class=\"wpforms-field-medium\" name=\"wpforms[fields][126]\" aria-errormessage=\"wpforms-594-field_126-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_127-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"127\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_127\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_127\" class=\"wpforms-field-medium\" name=\"wpforms[fields][127]\" aria-errormessage=\"wpforms-594-field_127-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_128-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"128\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_128\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_128\" class=\"wpforms-field-medium\" name=\"wpforms[fields][128]\" aria-errormessage=\"wpforms-594-field_128-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_129-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"129\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_129\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_129\" class=\"wpforms-field-medium\" name=\"wpforms[fields][129]\" aria-errormessage=\"wpforms-594-field_129-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_130-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"130\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_130\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_130\" class=\"wpforms-field-medium\" name=\"wpforms[fields][130]\" aria-errormessage=\"wpforms-594-field_130-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_131-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"131\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_131\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_131\" class=\"wpforms-field-medium\" name=\"wpforms[fields][131]\" aria-errormessage=\"wpforms-594-field_131-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_132-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"132\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_132\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_132\" class=\"wpforms-field-medium\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-594-field_132-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_133-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"133\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_133\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_133\" class=\"wpforms-field-medium\" name=\"wpforms[fields][133]\" aria-errormessage=\"wpforms-594-field_133-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_134-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"134\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_134\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_134\" class=\"wpforms-field-medium\" name=\"wpforms[fields][134]\" aria-errormessage=\"wpforms-594-field_134-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_135-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"135\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_135\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_135\" class=\"wpforms-field-medium\" name=\"wpforms[fields][135]\" aria-errormessage=\"wpforms-594-field_135-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_136-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"136\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_136\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_136\" class=\"wpforms-field-medium\" name=\"wpforms[fields][136]\" aria-errormessage=\"wpforms-594-field_136-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_137-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"137\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_137\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_137\" class=\"wpforms-field-medium\" name=\"wpforms[fields][137]\" aria-errormessage=\"wpforms-594-field_137-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_138-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"138\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_138\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_138\" class=\"wpforms-field-medium\" name=\"wpforms[fields][138]\" aria-errormessage=\"wpforms-594-field_138-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_139-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"139\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_139\">Injury<\/label><input type=\"text\" id=\"wpforms-594-field_139\" class=\"wpforms-field-medium\" name=\"wpforms[fields][139]\" aria-errormessage=\"wpforms-594-field_139-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_140-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"140\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_140\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_140\" class=\"wpforms-field-medium\" name=\"wpforms[fields][140]\" aria-errormessage=\"wpforms-594-field_140-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_169-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"169\"><div id=\"wpforms-594-field_169\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_169-error\"><h4><span style=\"color:#0000ff\">SURGERIES<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-594-field_142-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-trigger\" data-field-id=\"142\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_142\">How many surgeries have you had?<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-594-field_142\" class=\"wpforms-field-medium\" name=\"wpforms[fields][142]\" value=\"0\" aria-errormessage=\"wpforms-594-field_142-error\"\t\tmin=\"0\"\n\tmax=\"8\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-594-field_143-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"143\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_144-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"144\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_144\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_144\" class=\"wpforms-field-medium\" name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-594-field_144-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_145-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"145\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_145\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_145\" class=\"wpforms-field-medium\" name=\"wpforms[fields][145]\" aria-errormessage=\"wpforms-594-field_145-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_146-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"146\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_146\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_146\" class=\"wpforms-field-medium\" name=\"wpforms[fields][146]\" aria-errormessage=\"wpforms-594-field_146-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_147-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"147\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_147\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_147\" class=\"wpforms-field-medium\" name=\"wpforms[fields][147]\" aria-errormessage=\"wpforms-594-field_147-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_148-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"148\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_148\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_148\" class=\"wpforms-field-medium\" name=\"wpforms[fields][148]\" aria-errormessage=\"wpforms-594-field_148-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_149-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"149\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_149\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_149\" class=\"wpforms-field-medium\" name=\"wpforms[fields][149]\" aria-errormessage=\"wpforms-594-field_149-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_150-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"150\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_150\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_150\" class=\"wpforms-field-medium\" name=\"wpforms[fields][150]\" aria-errormessage=\"wpforms-594-field_150-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_151-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"151\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_151\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_151\" class=\"wpforms-field-medium\" name=\"wpforms[fields][151]\" aria-errormessage=\"wpforms-594-field_151-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_152-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"152\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_152\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_152\" class=\"wpforms-field-medium\" name=\"wpforms[fields][152]\" aria-errormessage=\"wpforms-594-field_152-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_153-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"153\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_153\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_153\" class=\"wpforms-field-medium\" name=\"wpforms[fields][153]\" aria-errormessage=\"wpforms-594-field_153-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_154-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"154\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_154\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_154\" class=\"wpforms-field-medium\" name=\"wpforms[fields][154]\" aria-errormessage=\"wpforms-594-field_154-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_155-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"155\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_155\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_155\" class=\"wpforms-field-medium\" name=\"wpforms[fields][155]\" aria-errormessage=\"wpforms-594-field_155-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_156-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"156\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_156\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_156\" class=\"wpforms-field-medium\" name=\"wpforms[fields][156]\" aria-errormessage=\"wpforms-594-field_156-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_157-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"157\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_157\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_157\" class=\"wpforms-field-medium\" name=\"wpforms[fields][157]\" aria-errormessage=\"wpforms-594-field_157-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_159-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"159\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_159\">Surgery<\/label><input type=\"text\" id=\"wpforms-594-field_159\" class=\"wpforms-field-medium\" name=\"wpforms[fields][159]\" aria-errormessage=\"wpforms-594-field_159-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-594-field_160-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"160\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_160\">Comment<\/label><input type=\"text\" id=\"wpforms-594-field_160\" class=\"wpforms-field-medium\" name=\"wpforms[fields][160]\" aria-errormessage=\"wpforms-594-field_160-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_170-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"170\"><div id=\"wpforms-594-field_170\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-594-field_170-error\"><h4><span style=\"color:#0000ff\">ADDITIONAL INFO<\/span><\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-594-field_36-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_36\">Have Have You Had a Theraputic Massage Before?<\/label><select id=\"wpforms-594-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\"><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><\/select><\/div><div id=\"wpforms-594-field_37-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_37\">Are You Currently Under Care of a Physcian\/Chiropractor?<\/label><select id=\"wpforms-594-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-594-field_31-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_31\">If yes, please detail the reason<\/label><input type=\"text\" id=\"wpforms-594-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-594-field_31-error\" ><\/div><div id=\"wpforms-594-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_41\">Current Exercise\/Training Routine<\/label><textarea id=\"wpforms-594-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-594-field_41-error\" aria-describedby=\"wpforms-594-field_41-description\" ><\/textarea><div id=\"wpforms-594-field_41-description\" class=\"wpforms-field-description\">Please detail your current exercise schedule<\/div><\/div><div id=\"wpforms-594-field_42-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_42\">Please Detail Any Current Pain, Tension, or Discomfort Areas<\/label><textarea id=\"wpforms-594-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-594-field_42-error\" aria-describedby=\"wpforms-594-field_42-description\" ><\/textarea><div id=\"wpforms-594-field_42-description\" class=\"wpforms-field-description\">Arm, leg, neck, etc.<\/div><\/div><div id=\"wpforms-594-field_81-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">Insurance<\/legend><ul id=\"wpforms-594-field_81\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_81_1\" name=\"wpforms[fields][81][]\" value=\"I have insurance\" aria-errormessage=\"wpforms-594-field_81_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_81_1\">I have insurance<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_82-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"82\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_83-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"83\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_83\">Insurer<\/label><select id=\"wpforms-594-field_83\" class=\"wpforms-field-medium\" name=\"wpforms[fields][83]\"><option value=\"Blue Cross\"  class=\"choice-1 depth-1\"  >Blue Cross<\/option><option value=\"Canada Life\"  class=\"choice-2 depth-1\"  >Canada Life<\/option><option value=\"Chambers of Commerce\"  class=\"choice-3 depth-1\"  >Chambers of Commerce<\/option><option value=\"Desjardins\"  class=\"choice-4 depth-1\"  >Desjardins<\/option><option value=\"Equitable\"  class=\"choice-5 depth-1\"  >Equitable<\/option><option value=\"Green Shield Insurance (GSC)\"  class=\"choice-7 depth-1\"  >Green Shield Insurance (GSC)<\/option><option value=\"Industrial Alliance (IA)\"  class=\"choice-6 depth-1\"  >Industrial Alliance (IA)<\/option><option value=\"Manulife Financial\"  class=\"choice-8 depth-1\"  >Manulife Financial<\/option><option value=\"People Corporation\"  class=\"choice-10 depth-1\"  >People Corporation<\/option><option value=\"RBC\"  class=\"choice-9 depth-1\"  >RBC<\/option><option value=\"The co-operators\"  class=\"choice-11 depth-1\"  >The co-operators<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_86-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_86\">Policy Name<\/label><input type=\"text\" id=\"wpforms-594-field_86\" class=\"wpforms-field-medium\" name=\"wpforms[fields][86]\" aria-errormessage=\"wpforms-594-field_86-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_85-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_85\">Policy \/ Group \/ Plan #<\/label><input type=\"text\" id=\"wpforms-594-field_85\" class=\"wpforms-field-medium\" name=\"wpforms[fields][85]\" aria-errormessage=\"wpforms-594-field_85-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_87\">Member ID \/ Certificate<\/label><input type=\"text\" id=\"wpforms-594-field_87\" class=\"wpforms-field-medium\" name=\"wpforms[fields][87]\" aria-errormessage=\"wpforms-594-field_87-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_161-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"161\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_161\">Other Insurer not list above<\/label><input type=\"text\" id=\"wpforms-594-field_161\" class=\"wpforms-field-medium\" name=\"wpforms[fields][161]\" aria-errormessage=\"wpforms-594-field_161-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><\/div><\/div><\/div><\/div><div id=\"wpforms-594-field_88-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"88\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Policy Holder<\/legend><ul id=\"wpforms-594-field_88\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_88_1\" name=\"wpforms[fields][88][]\" value=\"I&#039;m not the policy holder\" aria-errormessage=\"wpforms-594-field_88_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_88_1\">I&#8217;m not the policy holder<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-594-field_89-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"89\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_90-container\" class=\"wpforms-field 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class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"92\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_92\">Relationship To Patient<\/label><select id=\"wpforms-594-field_92\" class=\"wpforms-field-medium\" name=\"wpforms[fields][92]\"><option value=\"Child\"  class=\"choice-1 depth-1\"  >Child<\/option><option value=\"Parent\"  class=\"choice-2 depth-1\"  >Parent<\/option><option value=\"Spouse\"  class=\"choice-3 depth-1\"  >Spouse<\/option><option value=\"Common Law Spouse\"  class=\"choice-4 depth-1\"  >Common Law Spouse<\/option><option value=\"Other\"  class=\"choice-5 depth-1\"  >Other<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_93-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" 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type=\"text\" id=\"wpforms-594-field_94\" class=\"wpforms-field-medium\" name=\"wpforms[fields][94]\" aria-errormessage=\"wpforms-594-field_94-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_95-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_95\">City<\/label><input type=\"text\" id=\"wpforms-594-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" aria-errormessage=\"wpforms-594-field_95-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_96\">Prov\/State<\/label><input type=\"text\" id=\"wpforms-594-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" aria-errormessage=\"wpforms-594-field_96-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-594-field_97\">Postal \/ Zip Code<\/label><input type=\"text\" id=\"wpforms-594-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-594-field_97-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-594-field_98-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"98\" style=\"display:none;\"><label class=\"wpforms-field-label\" 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aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-594-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-594-field_43_1\" name=\"wpforms[fields][43][]\" value=\"I hereby agree to the following terms and conditions:\" aria-errormessage=\"wpforms-594-field_43_1-error\" aria-describedby=\"wpforms-594-field_43-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-594-field_43_1\">I hereby agree to the following terms and conditions:<\/label><\/li><\/ul><div id=\"wpforms-594-field_43-description\" class=\"wpforms-field-description wpforms-disclaimer-description\">Welcome to OmniHealth. Because the Terms and Conditions contain legal obligations, please read them carefully.<br \/>\n<br \/>\n1. YOUR MASSAGE AGREEMENT<br \/>\n<br \/>\nBy agreeing to this, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use click agree.<br \/>\n<br \/>\n    PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.<br \/>\n<br \/>\n2 YOUR Traditional Chinese Medicine or Acupuncturist AGREEMENT<br \/>\n<br \/>\nI understand that some of the techniques used under the scope of Traditional Chinese Medicine include the use of sterile, single-use needles to penetrate the skin. Additional treatment methods can include, but are not limited to: acupuncture, acupressure, the electrical stimulation of needles, cupping or moxibustion, gua sha, and tuina. Before any of these procedures are performed, my practitioner will discuss my treatment options and only processed if my consent is given.<br \/>\n<br \/>\nMy practitioner has informed me the risks and symptoms of treatments, which can include, but are not limited to: slight pain, light-headedness or nausea, soreness, bruising, bleeding or discoloration of the skin, and the possibility of other unforeseen risks. I freely accept the risks involved with my procedure.<br \/>\n<br \/>\nI will inform my practitioner if I currently have or develop any major health issues, if I suffer from any type of major bleeding disorder, or if I use a pacemaker.<br \/>\n<br \/>\nI understand that I must let my practitioner know I am carrying, or believe to have any infectious agents, including but at not limited to HIV, TB and Hepatitis. In some cases where cross-infection is high, my practitioner may withhold treatment.<br \/>\n<br \/>\nI understand that there are no guarantees for the results of my treatment. Traditional Chinese Medicine does not often provide an instant cure. The length of my treatment depends on the severity of my condition. In some cases my symptoms may temporarily worsen before they begin to improve.<br \/>\n<br \/>\nI understand that the fees charged for my treatment are not covered under OHIP and must be covered in full by myself or through third party insurance. I am responsible for the full and prompt payment after services have been rendered.<br \/>\n<br \/>\nI discuss the content of this form with my practitioner. I acknowledge that I can ask any questions I may have and receive answers I understand. By signing this form, I give my informed consent for Traditional Chinese Medicine treatments.<br \/>\n<br \/>\n3. 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