{"id":47,"date":"2020-07-16T06:55:21","date_gmt":"2020-07-16T10:55:21","guid":{"rendered":"https:\/\/orthoperfection.com\/protocole_en_en\/?page_id=47"},"modified":"2020-07-16T08:08:14","modified_gmt":"2020-07-16T12:08:14","slug":"questionnaire-medico-dentaire","status":"publish","type":"page","link":"https:\/\/orthoperfection.com\/protocole_en\/","title":{"rendered":"Questionnaire m\u00e9dico-dentaire"},"content":{"rendered":"<p><strong><span style=\"font-size: 28px; color: #77787b;\">Medical and Dental Questionnaire<\/span><\/strong><\/p>\n<p>The following information is essential to obtain the best treatment possible.<br \/>\nPlease answer all the questions. This document will be kept strictly <strong>confidential<\/strong>.<br \/>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/protocole_en\/wp-json\/wp\/v2\/pages\/47' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_41\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ca006c;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">GENERAL INFORMATIONS<\/div><\/li><li id=\"field_5_173\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_173'>** Attention<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_5_173' type='text' value='* YES *' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_11\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>Patient\u2019s Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_5_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Patient&#039;s First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_123\" class=\"gfield gfield--type-text gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_123'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_5_123' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_35\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_5_35' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_35_2_container'><label for='input_5_35_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_35[]' id='input_5_35_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_35_1_container'><label for='input_5_35_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_35[]' id='input_5_35_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_35_3_container'><label for='input_5_35_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_35[]' id='input_5_35_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Genre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_13'>\n\t\t\t<li class='gchoice gchoice_5_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='M'  id='choice_5_13_0'    \/>\n\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='F'  id='choice_5_13_1'    \/>\n\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_36\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_36'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_5_36' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_38\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_38'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_5_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_37\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_5_37' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_34\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_5_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_34_1' id='input_5_34_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_34_2_container' >\n                                        <input type='text' name='input_34.2' id='input_5_34_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_34_2' id='input_5_34_2_label' class='gform-field-label gform-field-label--type-sub '>Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_5_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_34_3' id='input_5_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_34_4_container' >\n                                        <select name='input_34.4' id='input_5_34_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' selected='selected'>Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_34_4' id='input_5_34_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_5_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_34_5' id='input_5_34_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_5_34_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_126\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you under 18?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_126'>\n\t\t\t<li class='gchoice gchoice_5_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_5_126_0'    \/>\n\t\t\t\t<label for='choice_5_126_0' id='label_5_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_5_126_1'    \/>\n\t\t\t\t<label for='choice_5_126_1' id='label_5_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_46\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'>Parent 1 Name<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_127\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_127'>Phone Home<\/label><div class='ginput_container ginput_container_phone'><input name='input_127' id='input_5_127' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_128\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_128'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_128' id='input_5_128' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_129\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_129'>Phone Work<\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_5_129' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_130\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_130'>Parent 2 Name<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_5_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_133\" class=\"gfield gfield--type-phone gf_left_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_133'>Phone Home<\/label><div class='ginput_container ginput_container_phone'><input name='input_133' id='input_5_133' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_132\" class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_132'>Mobile<\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_5_132' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_131\" class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_131'>Phone Work<\/label><div class='ginput_container ginput_container_phone'><input name='input_131' id='input_5_131' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_134\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Person in charge of payments<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_134'>\n\t\t\t<li class='gchoice gchoice_5_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='Parent 1'  id='choice_5_134_0'    \/>\n\t\t\t\t<label for='choice_5_134_0' id='label_5_134_0' class='gform-field-label gform-field-label--type-inline'>Parent 1<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Parent 2'  id='choice_5_134_1'    \/>\n\t\t\t\t<label for='choice_5_134_1' id='label_5_134_1' class='gform-field-label gform-field-label--type-inline'>Parent 2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_134_2'>\n\t\t\t\t<input name='input_134' type='radio' value='Other'  id='choice_5_134_2'    \/>\n\t\t\t\t<label for='choice_5_134_2' id='label_5_134_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_47\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'>Specify other<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_40\" class=\"gfield gfield--type-email gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_5_40' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_135\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_135'>\n\t\t\t<li class='gchoice gchoice_5_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Yes'  id='choice_5_135_0'    \/>\n\t\t\t\t<label for='choice_5_135_0' id='label_5_135_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='No'  id='choice_5_135_1'    \/>\n\t\t\t\t<label for='choice_5_135_1' id='label_5_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_137\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_137'>You have been referred to our office by<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_5_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_42\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#ca006c;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">DENTAL HISTORY<\/div><\/li><li id=\"field_5_139\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_139'>Name of your current dentist: Dr.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_5_139' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_15\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Last visit at the dentist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_15'>\n\t\t\t<li class='gchoice gchoice_5_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='0-6 months'  id='choice_5_15_0'    \/>\n\t\t\t\t<label for='choice_5_15_0' id='label_5_15_0' class='gform-field-label gform-field-label--type-inline'>0-6 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='6-12 months'  id='choice_5_15_1'    \/>\n\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>6-12 months<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_15_2'>\n\t\t\t\t<input name='input_15' type='radio' value='12+ months'  id='choice_5_15_2'    \/>\n\t\t\t\t<label for='choice_5_15_2' id='label_5_15_2' class='gform-field-label gform-field-label--type-inline'>12+ months<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_142\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a panoramic x-ray in the past year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_142'>\n\t\t\t<li class='gchoice gchoice_5_142_0'>\n\t\t\t\t<input name='input_142' type='radio' value='Yes'  id='choice_5_142_0'    \/>\n\t\t\t\t<label for='choice_5_142_0' id='label_5_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_142_1'>\n\t\t\t\t<input name='input_142' type='radio' value='No'  id='choice_5_142_1'    \/>\n\t\t\t\t<label for='choice_5_142_1' id='label_5_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_141\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of radiography<\/label><div id='input_5_141' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_141_2_container'><label for='input_5_141_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_141[]' id='input_5_141_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_141_1_container'><label for='input_5_141_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_141[]' id='input_5_141_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_141_3_container'><label for='input_5_141_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_141[]' id='input_5_141_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_143\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had an orthodontic consultation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_143'>\n\t\t\t<li class='gchoice gchoice_5_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Yes'  id='choice_5_143_0'    \/>\n\t\t\t\t<label for='choice_5_143_0' id='label_5_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='No'  id='choice_5_143_1'    \/>\n\t\t\t\t<label for='choice_5_143_1' id='label_5_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_144\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of orthodontic consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_5_144' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_144_2_container'><label for='input_5_144_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_144[]' id='input_5_144_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_144_1_container'><label for='input_5_144_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_144[]' id='input_5_144_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_144_3_container'><label for='input_5_144_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_144[]' id='input_5_144_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_145\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you play a musical instrument?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_145'>\n\t\t\t<li class='gchoice gchoice_5_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Yes'  id='choice_5_145_0'    \/>\n\t\t\t\t<label for='choice_5_145_0' id='label_5_145_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='No'  id='choice_5_145_1'    \/>\n\t\t\t\t<label for='choice_5_145_1' id='label_5_145_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_136\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_136'>Which one?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_5_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_147\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had an accident involving the head or face?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_147'>\n\t\t\t<li class='gchoice gchoice_5_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Yes'  id='choice_5_147_0'    \/>\n\t\t\t\t<label for='choice_5_147_0' id='label_5_147_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='No'  id='choice_5_147_1'    \/>\n\t\t\t\t<label for='choice_5_147_1' id='label_5_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_148\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had a dental trauma (blow to the teeth, fracture of a tooth or teeth, etc.) ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_148'>\n\t\t\t<li class='gchoice gchoice_5_148_0'>\n\t\t\t\t<input name='input_148' type='radio' value='Yes'  id='choice_5_148_0'    \/>\n\t\t\t\t<label for='choice_5_148_0' id='label_5_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_148_1'>\n\t\t\t\t<input name='input_148' type='radio' value='No'  id='choice_5_148_1'    \/>\n\t\t\t\t<label for='choice_5_148_1' id='label_5_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_149\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had surgery on the head, the face, the jaws or in the mouth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_149'>\n\t\t\t<li class='gchoice gchoice_5_149_0'>\n\t\t\t\t<input name='input_149' type='radio' value='Yes'  id='choice_5_149_0'    \/>\n\t\t\t\t<label for='choice_5_149_0' id='label_5_149_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_149_1'>\n\t\t\t\t<input name='input_149' type='radio' value='No'  id='choice_5_149_1'    \/>\n\t\t\t\t<label for='choice_5_149_1' id='label_5_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_150\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had orthodontic treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_150'>\n\t\t\t<li class='gchoice gchoice_5_150_0'>\n\t\t\t\t<input name='input_150' type='radio' value='Yes'  id='choice_5_150_0'    \/>\n\t\t\t\t<label for='choice_5_150_0' id='label_5_150_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_150_1'>\n\t\t\t\t<input name='input_150' type='radio' value='No'  id='choice_5_150_1'    \/>\n\t\t\t\t<label for='choice_5_150_1' id='label_5_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_151\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had teeth extracted for orthodontic reasons?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_151'>\n\t\t\t<li class='gchoice gchoice_5_151_0'>\n\t\t\t\t<input name='input_151' type='radio' value='Yes'  id='choice_5_151_0'    \/>\n\t\t\t\t<label for='choice_5_151_0' id='label_5_151_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_151_1'>\n\t\t\t\t<input name='input_151' type='radio' value='No'  id='choice_5_151_1'    \/>\n\t\t\t\t<label for='choice_5_151_1' id='label_5_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_152\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have any trouble opening your mouth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_152'>\n\t\t\t<li class='gchoice gchoice_5_152_0'>\n\t\t\t\t<input name='input_152' type='radio' value='Yes'  id='choice_5_152_0'    \/>\n\t\t\t\t<label for='choice_5_152_0' id='label_5_152_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_152_1'>\n\t\t\t\t<input name='input_152' type='radio' value='No'  id='choice_5_152_1'    \/>\n\t\t\t\t<label for='choice_5_152_1' id='label_5_152_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_153\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do your jaw joints crack or make noises?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_153'>\n\t\t\t<li class='gchoice gchoice_5_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='Yes'  id='choice_5_153_0'    \/>\n\t\t\t\t<label for='choice_5_153_0' id='label_5_153_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_5_153_1'    \/>\n\t\t\t\t<label for='choice_5_153_1' id='label_5_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_154\" class=\"gfield gfield--type-radio gfield--type-choice gf_middle_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do your gums bleed?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_154'>\n\t\t\t<li class='gchoice gchoice_5_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='Yes'  id='choice_5_154_0'    \/>\n\t\t\t\t<label for='choice_5_154_0' id='label_5_154_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='No'  id='choice_5_154_1'    \/>\n\t\t\t\t<label for='choice_5_154_1' id='label_5_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_155\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are your teeth sensitive?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_155'>\n\t\t\t<li class='gchoice gchoice_5_155_0'>\n\t\t\t\t<input name='input_155' type='radio' value='Yes'  id='choice_5_155_0'    \/>\n\t\t\t\t<label for='choice_5_155_0' id='label_5_155_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_155_1'>\n\t\t\t\t<input name='input_155' type='radio' value='No'  id='choice_5_155_1'    \/>\n\t\t\t\t<label for='choice_5_155_1' id='label_5_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_156\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Oral Habits (check all that apply)<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_156'><li class='gchoice gchoice_5_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Thumb sucking'  id='choice_5_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_1' id='label_5_156_1' class='gform-field-label gform-field-label--type-inline'>Thumb sucking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.2' type='checkbox'  value='Tongue thrusting'  id='choice_5_156_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_2' id='label_5_156_2' class='gform-field-label gform-field-label--type-inline'>Tongue thrusting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.3' type='checkbox'  value='Mouth breathing'  id='choice_5_156_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_3' id='label_5_156_3' class='gform-field-label gform-field-label--type-inline'>Mouth breathing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.4' type='checkbox'  value='Speech impediment'  id='choice_5_156_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_4' id='label_5_156_4' class='gform-field-label gform-field-label--type-inline'>Speech impediment<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.5' type='checkbox'  value='Lip biting'  id='choice_5_156_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_5' id='label_5_156_5' class='gform-field-label gform-field-label--type-inline'>Lip biting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.6' type='checkbox'  value='Nail biting'  id='choice_5_156_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_6' id='label_5_156_6' class='gform-field-label gform-field-label--type-inline'>Nail biting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.7' type='checkbox'  value='Jaw clenching'  id='choice_5_156_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_7' id='label_5_156_7' class='gform-field-label gform-field-label--type-inline'>Jaw clenching<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.8' type='checkbox'  value='Tooth grinding'  id='choice_5_156_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_8' id='label_5_156_8' class='gform-field-label gform-field-label--type-inline'>Tooth grinding<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_5_156_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.9' type='checkbox'  value='Other'  id='choice_5_156_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_156_9' id='label_5_156_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_146\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_146'>Specify other habit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_5_146' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_138\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#ca006c;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">MEDICAL HISTORY<\/div><\/li><li id=\"field_5_157\" class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_157'>Name and address of your family doctor: Dr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_5_157' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_158\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of your last medical examination<\/label><div id='input_5_158' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_158_2_container'><label for='input_5_158_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_158[]' id='input_5_158_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_158_1_container'><label for='input_5_158_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_158[]' id='input_5_158_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_158_3_container'><label for='input_5_158_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_158[]' id='input_5_158_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_5_140\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you presently under the care of a physician?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_140'>\n\t\t\t<li class='gchoice gchoice_5_140_0'>\n\t\t\t\t<input name='input_140' type='radio' value='Yes'  id='choice_5_140_0'    \/>\n\t\t\t\t<label for='choice_5_140_0' id='label_5_140_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_140_1'>\n\t\t\t\t<input name='input_140' type='radio' value='No'  id='choice_5_140_1'    \/>\n\t\t\t\t<label for='choice_5_140_1' id='label_5_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_51\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_51'>If so, for what reason?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_50\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take any medication or have you taken any in the last six months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_50'>\n\t\t\t<li class='gchoice gchoice_5_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_5_50_0'    \/>\n\t\t\t\t<label for='choice_5_50_0' id='label_5_50_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_5_50_1'    \/>\n\t\t\t\t<label for='choice_5_50_1' id='label_5_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_159\" class=\"gfield gfield--type-text gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_159'>If so, which ones?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_5_159' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_52\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take the birth control pill?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_52'>\n\t\t\t<li class='gchoice gchoice_5_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_5_52_0'    \/>\n\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_5_52_1'    \/>\n\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_160\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_160'>Teenage girls: Did you have your first period? If so, at what age?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_5_160' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_161\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_161'>Teenage boys: Did your voice start changing? If so, at what age?<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_5_161' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_16\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_16'>\n\t\t\t<li class='gchoice gchoice_5_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_5_16_0'    \/>\n\t\t\t\t<label for='choice_5_16_0' id='label_5_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_5_16_1'    \/>\n\t\t\t\t<label for='choice_5_16_1' id='label_5_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_53\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you smoke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_53'>\n\t\t\t<li class='gchoice gchoice_5_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_5_53_0'    \/>\n\t\t\t\t<label for='choice_5_53_0' id='label_5_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_5_53_1'    \/>\n\t\t\t\t<label for='choice_5_53_1' id='label_5_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_163\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you ever have an allergic reaction to  medication, food, nickel or any other substance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_163'>\n\t\t\t<li class='gchoice gchoice_5_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='Yes'  id='choice_5_163_0'    \/>\n\t\t\t\t<label for='choice_5_163_0' id='label_5_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='No'  id='choice_5_163_1'    \/>\n\t\t\t\t<label for='choice_5_163_1' id='label_5_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_164\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_164'>If so, specify:<\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_5_164' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_165\" class=\"gfield gfield--type-radio gfield--type-choice gf_left gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever been hospitalized?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_165'>\n\t\t\t<li class='gchoice gchoice_5_165_0'>\n\t\t\t\t<input name='input_165' type='radio' value='Yes'  id='choice_5_165_0'    \/>\n\t\t\t\t<label for='choice_5_165_0' id='label_5_165_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_165_1'>\n\t\t\t\t<input name='input_165' type='radio' value='No'  id='choice_5_165_1'    \/>\n\t\t\t\t<label for='choice_5_165_1' id='label_5_165_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_166\" class=\"gfield gfield--type-text gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_166'>If so, for what reason?<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_5_166' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_167\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ffffff;color:#545454;font-weight:bold;font-size:18px;\">Do you suffer or have you ever suffered from the following?<\/div><\/li><li id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Heart problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_54'>\n\t\t\t<li class='gchoice gchoice_5_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_5_54_0'    \/>\n\t\t\t\t<label for='choice_5_54_0' id='label_5_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_5_54_1'    \/>\n\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_55\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rhumatic fever or endocarditis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_55'>\n\t\t\t<li class='gchoice gchoice_5_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='Yes'  id='choice_5_55_0'    \/>\n\t\t\t\t<label for='choice_5_55_0' id='label_5_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_5_55_1'    \/>\n\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_60\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Prolonged bleeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_60'>\n\t\t\t<li class='gchoice gchoice_5_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='Yes'  id='choice_5_60_0'    \/>\n\t\t\t\t<label for='choice_5_60_0' id='label_5_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='No'  id='choice_5_60_1'    \/>\n\t\t\t\t<label for='choice_5_60_1' id='label_5_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_56\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Anemia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_56'>\n\t\t\t<li class='gchoice gchoice_5_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_5_56_0'    \/>\n\t\t\t\t<label for='choice_5_56_0' id='label_5_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_5_56_1'    \/>\n\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_57\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood pressure problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_57'>\n\t\t\t<li class='gchoice gchoice_5_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes- High'  id='choice_5_57_0'    \/>\n\t\t\t\t<label for='choice_5_57_0' id='label_5_57_0' class='gform-field-label gform-field-label--type-inline'>Yes- High<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes - Low'  id='choice_5_57_1'    \/>\n\t\t\t\t<label for='choice_5_57_1' id='label_5_57_1' class='gform-field-label gform-field-label--type-inline'>Yes - Low<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_5_57_2'    \/>\n\t\t\t\t<label for='choice_5_57_2' id='label_5_57_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_58\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent colds or sinusitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_58'>\n\t\t\t<li class='gchoice gchoice_5_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_5_58_0'    \/>\n\t\t\t\t<label for='choice_5_58_0' id='label_5_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_5_58_1'    \/>\n\t\t\t\t<label for='choice_5_58_1' id='label_5_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_59\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tuberculosis or lung problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_59'>\n\t\t\t<li class='gchoice gchoice_5_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_5_59_0'    \/>\n\t\t\t\t<label for='choice_5_59_0' id='label_5_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_5_59_1'    \/>\n\t\t\t\t<label for='choice_5_59_1' id='label_5_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_76\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_76'>\n\t\t\t<li class='gchoice gchoice_5_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Yes'  id='choice_5_76_0'    \/>\n\t\t\t\t<label for='choice_5_76_0' id='label_5_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='No'  id='choice_5_76_1'    \/>\n\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_168\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Removal of tonsils or adenoids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_168'>\n\t\t\t<li class='gchoice gchoice_5_168_0'>\n\t\t\t\t<input name='input_168' type='radio' value='Yes'  id='choice_5_168_0'    \/>\n\t\t\t\t<label for='choice_5_168_0' id='label_5_168_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_168_1'>\n\t\t\t\t<input name='input_168' type='radio' value='No'  id='choice_5_168_1'    \/>\n\t\t\t\t<label for='choice_5_168_1' id='label_5_168_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_170\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >HIV virus carrier<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_170'>\n\t\t\t<li class='gchoice gchoice_5_170_0'>\n\t\t\t\t<input name='input_170' type='radio' value='Yes'  id='choice_5_170_0'    \/>\n\t\t\t\t<label for='choice_5_170_0' id='label_5_170_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_170_1'>\n\t\t\t\t<input name='input_170' type='radio' value='No'  id='choice_5_170_1'    \/>\n\t\t\t\t<label for='choice_5_170_1' id='label_5_170_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_171\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Psychological or emotional disorder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_171'>\n\t\t\t<li class='gchoice gchoice_5_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='Yes'  id='choice_5_171_0'    \/>\n\t\t\t\t<label for='choice_5_171_0' id='label_5_171_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='No'  id='choice_5_171_1'    \/>\n\t\t\t\t<label for='choice_5_171_1' id='label_5_171_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_169\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Digestive problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_169'>\n\t\t\t<li class='gchoice gchoice_5_169_0'>\n\t\t\t\t<input name='input_169' type='radio' value='Yes'  id='choice_5_169_0'    \/>\n\t\t\t\t<label for='choice_5_169_0' id='label_5_169_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_169_1'>\n\t\t\t\t<input name='input_169' type='radio' value='No'  id='choice_5_169_1'    \/>\n\t\t\t\t<label for='choice_5_169_1' id='label_5_169_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_62\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Liver problems (hepatitis, cirrhosis)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_62'>\n\t\t\t<li class='gchoice gchoice_5_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Yes'  id='choice_5_62_0'    \/>\n\t\t\t\t<label for='choice_5_62_0' id='label_5_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='No'  id='choice_5_62_1'    \/>\n\t\t\t\t<label for='choice_5_62_1' id='label_5_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_63\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Kidney problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_63'>\n\t\t\t<li class='gchoice gchoice_5_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_5_63_0'    \/>\n\t\t\t\t<label for='choice_5_63_0' id='label_5_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_5_63_1'    \/>\n\t\t\t\t<label for='choice_5_63_1' id='label_5_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_64\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sexually transmitted disease (STD)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_64'>\n\t\t\t<li class='gchoice gchoice_5_64_0'>\n\t\t\t\t<input name='input_64' type='radio' value='Yes'  id='choice_5_64_0'    \/>\n\t\t\t\t<label for='choice_5_64_0' id='label_5_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_64_1'>\n\t\t\t\t<input name='input_64' type='radio' value='No'  id='choice_5_64_1'    \/>\n\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_65\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_65'>\n\t\t\t<li class='gchoice gchoice_5_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_5_65_0'    \/>\n\t\t\t\t<label for='choice_5_65_0' id='label_5_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_5_65_1'    \/>\n\t\t\t\t<label for='choice_5_65_1' id='label_5_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Thyroid problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_66'>\n\t\t\t<li class='gchoice gchoice_5_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes'  id='choice_5_66_0'    \/>\n\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_5_66_1'    \/>\n\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_67\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Skin disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_67'>\n\t\t\t<li class='gchoice gchoice_5_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Yes'  id='choice_5_67_0'    \/>\n\t\t\t\t<label for='choice_5_67_0' id='label_5_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='No'  id='choice_5_67_1'    \/>\n\t\t\t\t<label for='choice_5_67_1' id='label_5_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_68\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Eye problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_68'>\n\t\t\t<li class='gchoice gchoice_5_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Yes'  id='choice_5_68_0'    \/>\n\t\t\t\t<label for='choice_5_68_0' id='label_5_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='No'  id='choice_5_68_1'    \/>\n\t\t\t\t<label for='choice_5_68_1' id='label_5_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_69\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Arthritis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_69'>\n\t\t\t<li class='gchoice gchoice_5_69_0'>\n\t\t\t\t<input name='input_69' type='radio' value='Yes'  id='choice_5_69_0'    \/>\n\t\t\t\t<label for='choice_5_69_0' id='label_5_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_69_1'>\n\t\t\t\t<input name='input_69' type='radio' value='No'  id='choice_5_69_1'    \/>\n\t\t\t\t<label for='choice_5_69_1' id='label_5_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_70\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Epilepsy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_70'>\n\t\t\t<li class='gchoice gchoice_5_70_0'>\n\t\t\t\t<input name='input_70' type='radio' value='Yes'  id='choice_5_70_0'    \/>\n\t\t\t\t<label for='choice_5_70_0' id='label_5_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_70_1'>\n\t\t\t\t<input name='input_70' type='radio' value='No'  id='choice_5_70_1'    \/>\n\t\t\t\t<label for='choice_5_70_1' id='label_5_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_72\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_72'>\n\t\t\t<li class='gchoice gchoice_5_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_5_72_0'    \/>\n\t\t\t\t<label for='choice_5_72_0' id='label_5_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_5_72_1'    \/>\n\t\t\t\t<label for='choice_5_72_1' id='label_5_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_73\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dizzyness, fainting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_73'>\n\t\t\t<li class='gchoice gchoice_5_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_5_73_0'    \/>\n\t\t\t\t<label for='choice_5_73_0' id='label_5_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_5_73_1'    \/>\n\t\t\t\t<label for='choice_5_73_1' id='label_5_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_74\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Earaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_74'>\n\t\t\t<li class='gchoice gchoice_5_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_5_74_0'    \/>\n\t\t\t\t<label for='choice_5_74_0' id='label_5_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_5_74_1'    \/>\n\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_75\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hay fever<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_75'>\n\t\t\t<li class='gchoice gchoice_5_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Yes'  id='choice_5_75_0'    \/>\n\t\t\t\t<label for='choice_5_75_0' id='label_5_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='No'  id='choice_5_75_1'    \/>\n\t\t\t\t<label for='choice_5_75_1' id='label_5_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_77\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Persistent cough<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_77'>\n\t\t\t<li class='gchoice gchoice_5_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Yes'  id='choice_5_77_0'    \/>\n\t\t\t\t<label for='choice_5_77_0' id='label_5_77_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='No'  id='choice_5_77_1'    \/>\n\t\t\t\t<label for='choice_5_77_1' id='label_5_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_78\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Mononucleosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_78'>\n\t\t\t<li class='gchoice gchoice_5_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Yes'  id='choice_5_78_0'    \/>\n\t\t\t\t<label for='choice_5_78_0' id='label_5_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='No'  id='choice_5_78_1'    \/>\n\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_79\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Radiation therapy for tumor or other reasons<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_79'>\n\t\t\t<li class='gchoice gchoice_5_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_5_79_0'    \/>\n\t\t\t\t<label for='choice_5_79_0' id='label_5_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_5_79_1'    \/>\n\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_120\" class=\"gfield gfield--type-textarea gf_left field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_120'>Other pertinent medical or dental information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_5_120' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_91\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#ca006c;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">ACCEPTANCE<\/div><\/li><li id=\"field_5_88\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Medical and dental history<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_88.1' id='input_5_88_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_88_1' >I hereby declare that I have read, understood, and answered the above medical and dental questionnaire to the best of my knowledge.<\/label><input type='hidden' name='input_88.2' value='I hereby declare that I have read, understood, and answered the above medical and dental questionnaire to the best of my knowledge.' class='gform_hidden' \/><input type='hidden' name='input_88.3' value='3' class='gform_hidden' \/><\/div><\/li><li id=\"field_5_176\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of Collection, use, and disclosure of personal information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_176.1' id='input_5_176_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_176\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_176_1' >I hereby give my consent to the collection, use and disclosure of my personal information by ORTHO PERFECTION for the purpose of providing dental services.<\/label><input type='hidden' name='input_176.2' value='I hereby give my consent to the collection, use and disclosure of my personal information by ORTHO PERFECTION for the purpose of providing dental services.' class='gform_hidden' \/><input type='hidden' name='input_176.3' value='3' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_176' tabindex='0'>Read our <a href=\"https:\/\/orthoperfection.com\/politiqueconfidentialite_en.html\" target=\"_blank\">Privacy Policy<\/a><\/div><\/li><li id=\"field_5_2\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_2'>Patient or Parent Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_2' id='input_5_2_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_2_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_5_2' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #ca006c; background-color:#ebebeb; cursor: url(https:\/\/orthoperfection.com\/protocole_en\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_2_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_5_2_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_5_2_data' name='input_5_2_data' value=''><\/div><\/li><li id=\"field_5_172\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_172'>Printed name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_5_172' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_33\" class=\"gfield gfield--type-text gf_readonly field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_33'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='15 mai 2026 04h42' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_175\" class=\"gfield gfield--type-checkbox gfield--type-choice gf_left blanc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_175'><li class='gchoice gchoice_5_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='R\u00e9serv\u00e9 \u00e0 l&#039;administration'  id='choice_5_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_175_1' id='label_5_175_1' class='gform-field-label gform-field-label--type-inline'>R\u00e9serv\u00e9 \u00e0 l'administration<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_110\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><div style=\"background-color:#545454;color:#ffffff;padding:5px;font-weight:bold;font-size:18px;\">RESERVED FOR ADMINISTRATION<\/div><\/li><li id=\"field_5_112\" class=\"gfield gfield--type-textarea grisadminn field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_112'>Notes<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_5_112' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_113\" class=\"gfield gfield--type-textarea grisadminn field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_113'>Precautions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_5_113' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_111\" class=\"gfield gfield--type-consent gfield--type-choice grisadminn gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Acceptance of the specialist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_111.1' id='input_5_111_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_111_1' >I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.<\/label><input type='hidden' name='input_111.2' value='I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.' class='gform_hidden' \/><input type='hidden' name='input_111.3' value='3' class='gform_hidden' \/><\/div><\/li><li id=\"field_5_117\" class=\"gfield gfield--type-signature grisadminn field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_117'>Specialist Signature<\/label><input type='hidden' value='' name='input_117' id='input_5_117_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_5_117_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><canvas id='input_5_117' width='600' height='180' style='border-style: solid; border-width: 1px; border-color: #545454; background-color:#ebebeb; cursor: url(https:\/\/orthoperfection.com\/protocole_en\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_5_117_toolbar' style='margin:5px 0;position:relative;height:20px;width:600px;max-width:100%;'><img id = 'input_5_117_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_5_117_data' name='input_5_117_data' value=''><\/div><\/li><li id=\"field_5_116\" class=\"gfield gfield--type-text grisadminn gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_116'>Specialist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_5_116' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_114\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon grisadminn field_sublabel_below gfield--no-description 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value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 5, 'https:\/\/orthoperfection.com\/protocole_en\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_5').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_5');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_5').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 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