{"id":1781,"date":"2018-04-29T21:12:01","date_gmt":"2018-04-29T21:12:01","guid":{"rendered":"https:\/\/oreme.eu\/faq\/"},"modified":"2026-03-24T21:29:03","modified_gmt":"2026-03-24T21:29:03","slug":"faq","status":"publish","type":"page","link":"https:\/\/oreme.eu\/de\/faq\/","title":{"rendered":"FAQ"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_section-9ef82359d32708e3522dda94d60f8ae3\">\n.avia-section.av-av_section-9ef82359d32708e3522dda94d60f8ae3 .av-section-color-overlay{\nopacity:0.1;\nbackground-color:#7294cd;\n}\n<\/style>\n<div id='av_section_1'  class='avia-section av-av_section-9ef82359d32708e3522dda94d60f8ae3 main_color avia-section-default avia-no-shadow  avia-builder-el-0  avia-builder-el-no-sibling  avia-bg-style-scroll av-section-color-overlay-active container_wrap sidebar_right'  ><div class=\"av-section-color-overlay-wrap\"><div class=\"av-section-color-overlay\"><\/div><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-1781'><div class='entry-content-wrapper clearfix'>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_one_full-f72e7ad6b64d2d9bf1d798755ec1ce61\">\n.flex_column.av-av_one_full-f72e7ad6b64d2d9bf1d798755ec1ce61{\nborder-radius:0px 0px 0px 0px;\npadding:0px 0px 0px 0px;\n}\n<\/style>\n<div  class='flex_column av-av_one_full-f72e7ad6b64d2d9bf1d798755ec1ce61 av_one_full  avia-builder-el-1  el_before_av_one_full  avia-builder-el-first  first flex_column_div av-animated-generic bottom-to-top av-zero-column-padding  '     ><p>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_heading-474cdac73c331964b3da3f97a1a040a7\">\n#top .av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7{\npadding-bottom:20px;\nfont-size:34px;\n}\nbody .av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7 .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n#top #wrap_all .av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7 .av-special-heading-tag{\nfont-size:34px;\n}\n.av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7 .av-subheading{\nfont-size:15px;\n}\n\n@media only screen and (min-width: 480px) and (max-width: 767px){ \n#top #wrap_all .av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7 .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n\n@media only screen and (max-width: 479px){ \n#top #wrap_all .av-special-heading.av-av_heading-474cdac73c331964b3da3f97a1a040a7 .av-special-heading-tag{\nfont-size:0.8em;\n}\n}\n<\/style>\n<div  class='av-special-heading av-av_heading-474cdac73c331964b3da3f97a1a040a7 av-special-heading-h3 blockquote modern-quote  avia-builder-el-2  el_before_av_toggle_container  avia-builder-el-first  av-inherit-size'><h3 class='av-special-heading-tag '  itemprop=\"headline\"  >H\u00e4ufig gestellte Fragen (FAQ)<\/h3><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div><br \/>\n<div  class='togglecontainer av-jo7o58eb-fee7d1070a6203d8c2f507d532374bac av-minimal-toggle  avia-builder-el-3  el_after_av_heading  avia-builder-el-last  toggle_close_all' >\n<section class='av_toggle_section av-mn53kdbm-fa310ad43bf27ef163758302267324de'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-1' data-fake-id='#toggle-id-1' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-1' data-slide-speed=\"200\" data-title=\"Behandlungskosten?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Behandlungskosten?\" data-aria_expanded=\"Click to collapse: Behandlungskosten?\">Behandlungskosten?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-1' aria-labelledby='toggle-toggle-id-1' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Die genauen Kosten einer Behandlung werden nach der Patientenbewertung festgelegt. Sie h\u00e4ngen von der Schwere der Verletzung und der Art der Behandlung ab.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53l8nn-caf308e619ddafcced5cc92bb4140dd5'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-2' data-fake-id='#toggle-id-2' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-2' data-slide-speed=\"200\" data-title=\"Bieten Sie Rabatte an? \" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Bieten Sie Rabatte an? \" data-aria_expanded=\"Click to collapse: Bieten Sie Rabatte an? \">Bieten Sie Rabatte an? <span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-2' aria-labelledby='toggle-toggle-id-2' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Leider k\u00f6nnen wir keine \u00a0Rabatte anbieten, weil dies gegen die in der Schweiz geltenden \u00e4rzterechtlichen Vorschriften versto\u00dfen w\u00fcrde.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53lkam-7d1d4bfea91de6f78695240189bb72e1'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-3' data-fake-id='#toggle-id-3' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-3' data-slide-speed=\"200\" data-title=\"Zahlt meine Versicherung die Behandlung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Zahlt meine Versicherung die Behandlung?\" data-aria_expanded=\"Click to collapse: Zahlt meine Versicherung die Behandlung?\">Zahlt meine Versicherung die Behandlung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-3' aria-labelledby='toggle-toggle-id-3' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Bitte beachten Sie, dass die Kosten unserer Behandlungen durch Krankenversicherungen derzeit nicht gedeckt werden.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53lu8w-5e89f7f0d893ca08d307b835a2474096'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-4' data-fake-id='#toggle-id-4' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-4' data-slide-speed=\"200\" data-title=\"Was, wenn ich die Behandlungskosten nicht aufbringen kann?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Was, wenn ich die Behandlungskosten nicht aufbringen kann?\" data-aria_expanded=\"Click to collapse: Was, wenn ich die Behandlungskosten nicht aufbringen kann?\">Was, wenn ich die Behandlungskosten nicht aufbringen kann?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-4' aria-labelledby='toggle-toggle-id-4' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Ihre Gesundheit sollte f\u00fcr Sie an erster Stelle stehen. F\u00fcr jedes Problem gibt es eine L\u00f6sung! Gerne beraten wir Sie \u00fcber weitere M\u00f6glichkeiten und Alternativen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53n7tg-13da983d66edd4bd6e6804b16839ca82'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-5' data-fake-id='#toggle-id-5' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-5' data-slide-speed=\"200\" data-title=\"Kann ich einen Sprechstundentermin beim behandelnden Arzt bekommen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Kann ich einen Sprechstundentermin beim behandelnden Arzt bekommen?\" data-aria_expanded=\"Click to collapse: Kann ich einen Sprechstundentermin beim behandelnden Arzt bekommen?\">Kann ich einen Sprechstundentermin beim behandelnden Arzt bekommen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-5' aria-labelledby='toggle-toggle-id-5' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Ja, sicher! Bitte beachten Sie, dass der Arzt Patienten \u00a0konsultiert sobald \u00a0alle erforderlichen Dokumente vorliegen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53ogpn-48d8e0b5cc97475be10fac0a4eb3b775'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-6' data-fake-id='#toggle-id-6' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-6' data-slide-speed=\"200\" data-title=\"Welche Dokumente ben\u00f6tigt der Arzt f\u00fcr eine Beratung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Welche Dokumente ben\u00f6tigt der Arzt f\u00fcr eine Beratung?\" data-aria_expanded=\"Click to collapse: Welche Dokumente ben\u00f6tigt der Arzt f\u00fcr eine Beratung?\">Welche Dokumente ben\u00f6tigt der Arzt f\u00fcr eine Beratung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-6' aria-labelledby='toggle-toggle-id-6' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Erforderliche Dokumente sind: ein vollst\u00e4ndig ausgef\u00fclltes Kandidaten- und Patientenformular; ein MRT-Scan (Bilder in DICOM Format und Berichte in PDF).<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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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_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Medical history form (new)<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/de\/wp-json\/wp\/v2\/pages\/1781#gf_6' data-formid='6' novalidate>\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Schritt <span class='gf_step_current_page'>1<\/span> von <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_440\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_440'>Company<\/label><div class='ginput_container'><input name='input_440' id='input_6_440' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_440'>Dieses Feld dient zur Validierung und sollte nicht ver\u00e4ndert werden.<\/div><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Demographic Form<\/h2><\/li><li id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>Vorname<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Nachname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_2\" class=\"gfield gfield--type-text gfield--input-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_6_2'>Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_6_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_3\" class=\"gfield gfield--type-address gfield--input-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_city has_zip has_country ginput_container_address gform-grid-row' id='input_6_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_6_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_3_1' id='input_6_3_1_label' class='gform-field-label gform-field-label--type-sub '>Street & Nr.<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_6_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_3_3' id='input_6_3_3_label' class='gform-field-label gform-field-label--type-sub '>Ort<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_3.4' id='input_6_3_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_6_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_3_5' id='input_6_3_5_label' class='gform-field-label gform-field-label--type-sub '>PLZ<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_6_3_6_container' >\n                                        <select name='input_3.6' id='input_6_3_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albanien' >Albanien<\/option><option value='Algerien' >Algerien<\/option><option value='Amerikanisch-Samoa' >Amerikanisch-Samoa<\/option><option value='Amerikanische Jungferninseln' >Amerikanische Jungferninseln<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarktis' >Antarktis<\/option><option value='Antigua und Barbuda' >Antigua und Barbuda<\/option><option value='Argentinien' >Argentinien<\/option><option value='Armenien' >Armenien<\/option><option value='Aruba' >Aruba<\/option><option value='Aserbaidschan' >Aserbaidschan<\/option><option value='Australien' >Australien<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belgien' >Belgien<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivien' >Bolivien<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnien und Herzegowina' >Bosnien und Herzegowina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brasilien' >Brasilien<\/option><option value='Britische Jungferninseln' >Britische Jungferninseln<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgarien' >Bulgarien<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Caymen Inseln' >Caymen Inseln<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Congo' >Congo<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Deutschland' >Deutschland<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominikanische Republik' >Dominikanische Republik<\/option><option value='D\u00e4nemark' >D\u00e4nemark<\/option><option value='Ecuador' >Ecuador<\/option><option value='El Salvador' >El Salvador<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estland' >Estland<\/option><option value='Eswatini' >Eswatini<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroer-Inseln' >Faroer-Inseln<\/option><option value='Fidschi' >Fidschi<\/option><option value='Finnland' >Finnland<\/option><option value='Frankreich' >Frankreich<\/option><option value='Franz\u00f6sisch-Polynesien' >Franz\u00f6sisch-Polynesien<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenada' >Grenada<\/option><option value='Griechenland' >Griechenland<\/option><option value='Gro\u00dfbritannien' >Gro\u00dfbritannien<\/option><option value='Gr\u00f6nland' >Gr\u00f6nland<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hongkong' >Hongkong<\/option><option value='Indien' >Indien<\/option><option value='Indonesien' >Indonesien<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irland' >Irland<\/option><option value='Island' >Island<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italien' >Italien<\/option><option value='Jamaika' >Jamaika<\/option><option value='Japan' >Japan<\/option><option value='Jemen' >Jemen<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanien' >Jordanien<\/option><option value='Kambodscha' >Kambodscha<\/option><option value='Kamerun' >Kamerun<\/option><option value='Kanada' >Kanada<\/option><option value='Kasachstan' >Kasachstan<\/option><option value='Katar' >Katar<\/option><option value='Kenia' >Kenia<\/option><option value='Kirgistan' >Kirgistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kolumbien' >Kolumbien<\/option><option value='Komoren' >Komoren<\/option><option value='Kongo, Demokratische Republik des' >Kongo, Demokratische Republik des<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kroatien' >Kroatien<\/option><option value='Kuba' >Kuba<\/option><option value='Kuwait' >Kuwait<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettland' >Lettland<\/option><option value='Libanon' >Libanon<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Litauen' >Litauen<\/option><option value='Luxemburg' >Luxemburg<\/option><option value='Lybien' >Lybien<\/option><option value='Macao' >Macao<\/option><option value='Madagaskar' >Madagaskar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Malediven' >Malediven<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marokko' >Marokko<\/option><option value='Marshall-Inseln' >Marshall-Inseln<\/option><option value='Martinique' >Martinique<\/option><option value='Mauretanien' >Mauretanien<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexiko' >Mexiko<\/option><option value='Mikronesien' >Mikronesien<\/option><option value='Moldawien' >Moldawien<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolai' >Mongolai<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mosambik' >Mosambik<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Neuseeland' >Neuseeland<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niederlande' >Niederlande<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Norwegen' >Norwegen<\/option><option value='N\u00f6rdliche Marianen' >N\u00f6rdliche Marianen<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Pal\u00e4stina, Bundesstaat' >Pal\u00e4stina, Bundesstaat<\/option><option value='Panama' >Panama<\/option><option value='Papua Neu Guinea' >Papua Neu Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippinen' >Philippinen<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polen' >Polen<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Ruanda' >Ruanda<\/option><option value='Rum\u00e4nien' >Rum\u00e4nien<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Salomonen' >Salomonen<\/option><option value='Sambia' >Sambia<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Saudi-Arabien' >Saudi-Arabien<\/option><option value='Schweden' >Schweden<\/option><option value='Schweiz' >Schweiz<\/option><option value='Senegal' >Senegal<\/option><option value='Serbien' >Serbien<\/option><option value='Seychellen' >Seychellen<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Simbabwe' >Simbabwe<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovenien' >Slovenien<\/option><option value='Slowakei' >Slowakei<\/option><option value='Somalia' >Somalia<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spanien' >Spanien<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='St. Kitts und Nevis' >St. Kitts und Nevis<\/option><option value='St. Lucia' >St. Lucia<\/option><option value='St. Vincent und die Grenadinen' >St. Vincent und die Grenadinen<\/option><option value='Sudan' >Sudan<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='S\u00e3o Tom\u00e9 und Pr\u00edncipe' >S\u00e3o Tom\u00e9 und Pr\u00edncipe<\/option><option value='S\u00fcdafrika' >S\u00fcdafrika<\/option><option value='Tadschikistan' >Tadschikistan<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad und Tobago' >Trinidad und Tobago<\/option><option value='Tschad' >Tschad<\/option><option value='Tunesien' >Tunesien<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='U.S.A.' >U.S.A.<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='Ungarn' >Ungarn<\/option><option value='Uruguay' >Uruguay<\/option><option value='Usbekistan' >Usbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vereinigte Arabische Emirate' >Vereinigte Arabische Emirate<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Wei\u00dfrussland' >Wei\u00dfrussland<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Zentralafrikanische Republik' >Zentralafrikanische Republik<\/option><option value='Zypern' >Zypern<\/option><option value='\u00c4gypten' >\u00c4gypten<\/option><option value='\u00c4quatorial Guinea' >\u00c4quatorial Guinea<\/option><option value='\u00c4thopien' >\u00c4thopien<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='\u00d6sterreich' >\u00d6sterreich<\/option><\/select>\n                                        <label for='input_6_3_6' id='input_6_3_6_label' class='gform-field-label gform-field-label--type-sub '>Land<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_6_4\" class=\"gfield gfield--type-select gfield--input-type-select 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_6_4'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_6_4' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Single' >Single<\/option><option value='Married' >Married<\/option><option value='Divorced' >Divorced<\/option><option value='Widowed' >Widowed<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_6_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_5' class='gform_hidden' value='https:\/\/oreme.eu\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected'><\/option><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/li><li id=\"field_6_408\" class=\"gfield gfield--type-select gfield--input-type-select gf_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' for='input_6_408'>Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_408' id='input_6_408' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select country<\/option><option value='Afghanistan - +93' >Afghanistan - +93<\/option><option value='Albania - +355' >Albania - +355<\/option><option value='Algeria - +213' >Algeria - +213<\/option><option value='American Samoa - +684' >American Samoa - +684<\/option><option value='Andorra - +376' >Andorra - +376<\/option><option value='Angola - +244' >Angola - +244<\/option><option value='Antigua and Barbuda - +1-268' >Antigua and Barbuda - +1-268<\/option><option value='Argentina - +54' >Argentina - +54<\/option><option value='Armenia - +374' >Armenia - +374<\/option><option value='Australia - +61' >Australia - +61<\/option><option value='Austria - +43' >Austria - +43<\/option><option value='Azerbaijan - +994' >Azerbaijan - +994<\/option><option value='Bahamas - +1-242' >Bahamas - +1-242<\/option><option value='Bahrain - +973' >Bahrain - +973<\/option><option value='Bangladesh - +880' >Bangladesh - +880<\/option><option value='Barbados - +1-246' >Barbados - +1-246<\/option><option value='Belarus - +375' >Belarus - +375<\/option><option value='Belgium - +32' >Belgium - +32<\/option><option value='Belize - +501' >Belize - +501<\/option><option value='Benin - +229' >Benin - +229<\/option><option value='Bermuda - +10441' >Bermuda - +10441<\/option><option value='Bhutan - +975' >Bhutan - +975<\/option><option value='Bolivia - +591' >Bolivia - +591<\/option><option value='Bosnia and Herzegovina - +387' >Bosnia and Herzegovina - +387<\/option><option value='Botswana - +267' >Botswana - +267<\/option><option value='Brazil - +55' >Brazil - +55<\/option><option value='Brunei - +673' >Brunei - +673<\/option><option value='Bulgaria - +359' >Bulgaria - +359<\/option><option value='Burkina Faso - +226' >Burkina Faso - +226<\/option><option value='Burundi - +257' >Burundi - +257<\/option><option value='Cambodia - +855' >Cambodia - +855<\/option><option value='Cameroon - +237' >Cameroon - +237<\/option><option value='Canada - +1' >Canada - +1<\/option><option value='Cape Verde - +238' >Cape Verde - +238<\/option><option value='Cayman Islands - +1-345' >Cayman Islands - +1-345<\/option><option value='Central African Republic - +236' >Central African Republic - +236<\/option><option value='Chad - +235' >Chad - +235<\/option><option value='Chile - +56' >Chile - +56<\/option><option value='China - +86' >China - +86<\/option><option value='Colombia - +57' >Colombia - +57<\/option><option value='Comoros - +269' >Comoros - +269<\/option><option value='Congo, Democratic Republic of the - +243' >Congo, Democratic Republic of the - +243<\/option><option value='Congo, Republic of the - +242' >Congo, Republic of the - +242<\/option><option value='Costa Rica - +506' >Costa Rica - +506<\/option><option value='C\u00f4te d\\+Ivoire - +225' >C\u00f4te d\\+Ivoire - +225<\/option><option value='Croatia - +385' >Croatia - +385<\/option><option value='Cuba - +53' >Cuba - +53<\/option><option value='Cyprus - +357' >Cyprus - +357<\/option><option value='Czech Republic - +420' >Czech Republic - +420<\/option><option value='Denmark - +45' >Denmark - +45<\/option><option value='Djibouti - +253' >Djibouti - +253<\/option><option value='Dominica - +1-767' >Dominica - +1-767<\/option><option value='Dominican Republic - +1-809' >Dominican Republic - +1-809<\/option><option value='East Timor - +670' >East Timor - +670<\/option><option value='Ecuador - +593' >Ecuador - +593<\/option><option value='Egypt - +20' >Egypt - +20<\/option><option value='El Salvador - +503' >El Salvador - +503<\/option><option value='Equatorial Guinea - +240' >Equatorial Guinea - +240<\/option><option value='Eritrea - +291' >Eritrea - +291<\/option><option value='Estonia - +372' >Estonia - +372<\/option><option value='Ethiopia - +251' >Ethiopia - +251<\/option><option value='Fiji - +679' >Fiji - +679<\/option><option value='Finland - +358' >Finland - +358<\/option><option value='France - +33' >France - +33<\/option><option value='French Polynesia - +689' >French Polynesia - +689<\/option><option value='Gabon - +241' >Gabon - +241<\/option><option value='Gambia - +220' >Gambia - +220<\/option><option value='Georgia - +995' >Georgia - +995<\/option><option value='Germany - +49' >Germany - +49<\/option><option value='Ghana - +233' >Ghana - +233<\/option><option value='Greece - +30' >Greece - +30<\/option><option value='Greenland - +299' >Greenland - +299<\/option><option value='Grenada - +1-473' >Grenada - +1-473<\/option><option value='Guam - +1-671' >Guam - +1-671<\/option><option value='Guatemala - +502' >Guatemala - +502<\/option><option value='Guinea - +224' >Guinea - +224<\/option><option value='Guinea-Bissau - +245' >Guinea-Bissau - +245<\/option><option value='Guyana - +592' >Guyana - +592<\/option><option value='Haiti - +509' >Haiti - +509<\/option><option value='Honduras - +504' >Honduras - +504<\/option><option value='Hong Kong - +852' >Hong Kong - +852<\/option><option value='Hungary - +36' >Hungary - +36<\/option><option value='Iceland - +354' >Iceland - +354<\/option><option value='India - +91' >India - +91<\/option><option value='Indonesia - +62' >Indonesia - +62<\/option><option value='Iran - +98' >Iran - +98<\/option><option value='Iraq - +964' >Iraq - +964<\/option><option value='Ireland - +353' >Ireland - +353<\/option><option value='Israel - +972' >Israel - +972<\/option><option value='Italy - +39' >Italy - +39<\/option><option value='Jamaica - +1-876' >Jamaica - +1-876<\/option><option value='Japan - +81' >Japan - +81<\/option><option value='Jordan - +962' >Jordan - +962<\/option><option value='Kazakhstan - +7' >Kazakhstan - +7<\/option><option value='Kenya - +254' >Kenya - +254<\/option><option value='Kiribati - +686' >Kiribati - +686<\/option><option value='North Korea - +850' >North Korea - +850<\/option><option value='South Korea - +82' >South Korea - +82<\/option><option value='Kosovo - +381' >Kosovo - +381<\/option><option value='Kuwait - +965' >Kuwait - +965<\/option><option value='Kyrgyzstan - +996' >Kyrgyzstan - +996<\/option><option value='Laos - +856' >Laos - +856<\/option><option value='Latvia - +371' >Latvia - +371<\/option><option value='Lebanon - +961' >Lebanon - +961<\/option><option value='Lesotho - +266' >Lesotho - +266<\/option><option value='Liberia - +231' >Liberia - +231<\/option><option value='Libya - +218' >Libya - +218<\/option><option value='Liechtenstein - +423' >Liechtenstein - +423<\/option><option value='Lithuania - +370' >Lithuania - +370<\/option><option value='Luxembourg - +352' >Luxembourg - +352<\/option><option value='Macedonia - +389' >Macedonia - +389<\/option><option value='Madagascar - +261' >Madagascar - +261<\/option><option value='Malawi - +265' >Malawi - +265<\/option><option value='Malaysia - +60' >Malaysia - +60<\/option><option value='Maldives - +960' >Maldives - +960<\/option><option value='Mali - +223' >Mali - +223<\/option><option value='Malta - +356' >Malta - +356<\/option><option value='Marshall Islands - +692' >Marshall Islands - +692<\/option><option value='Mauritania - +222' >Mauritania - +222<\/option><option value='Mauritius - +230' >Mauritius - +230<\/option><option value='Mexico - +52' >Mexico - +52<\/option><option value='Micronesia - +691' >Micronesia - +691<\/option><option value='Moldova - +373' >Moldova - +373<\/option><option value='Monaco - +377' >Monaco - +377<\/option><option value='Mongolia - +976' >Mongolia - +976<\/option><option value='Montenegro - +382' >Montenegro - +382<\/option><option value='Morocco - +212' >Morocco - +212<\/option><option value='Mozambique - +258' >Mozambique - +258<\/option><option value='Myanmar - +95' >Myanmar - +95<\/option><option value='Namibia - +264' >Namibia - +264<\/option><option value='Nauru - +674' >Nauru - +674<\/option><option value='Nepal - +977' >Nepal - +977<\/option><option value='Netherlands - +31' >Netherlands - +31<\/option><option value='New Zealand - +64' >New Zealand - +64<\/option><option value='Nicaragua - +505' >Nicaragua - +505<\/option><option value='Niger - +227' >Niger - +227<\/option><option value='Nigeria - +234' >Nigeria - +234<\/option><option value='Norway - +47' >Norway - +47<\/option><option value='Northern Mariana Islands - +1-670' >Northern Mariana Islands - +1-670<\/option><option value='Oman - +968' >Oman - +968<\/option><option value='Pakistan - +92' >Pakistan - +92<\/option><option value='Palau - +680' >Palau - +680<\/option><option value='Palestine - +970' >Palestine - +970<\/option><option value='Panama - +507' >Panama - +507<\/option><option value='Papua New Guinea - +675' >Papua New Guinea - +675<\/option><option value='Paraguay - +595' >Paraguay - +595<\/option><option value='Peru - +51' >Peru - +51<\/option><option value='Philippines - +63' >Philippines - +63<\/option><option value='Poland - +48' >Poland - +48<\/option><option value='Portugal - +351' >Portugal - +351<\/option><option value='Puerto Rico - +1-939' >Puerto Rico - +1-939<\/option><option value='Qatar - +974' >Qatar - +974<\/option><option value='Romania - +40' >Romania - +40<\/option><option value='Russia - +7' >Russia - +7<\/option><option value='Rwanda - +250' >Rwanda - +250<\/option><option value='Saint Kitts and Nevis - +1-869' >Saint Kitts and Nevis - +1-869<\/option><option value='Saint Lucia - +1-758' >Saint Lucia - +1-758<\/option><option value='Saint Vincent and the Grenadines - +1-784' >Saint Vincent and the Grenadines - +1-784<\/option><option value='Samoa - +685' >Samoa - +685<\/option><option value='San Marino - +378' >San Marino - +378<\/option><option value='Sao Tome and Principe - +239' >Sao Tome and Principe - +239<\/option><option value='Saudi Arabia - +966' >Saudi Arabia - +966<\/option><option value='Senegal - +221' >Senegal - +221<\/option><option value='Serbia and Montenegro - +381' >Serbia and Montenegro - +381<\/option><option value='Seychelles - +248' >Seychelles - +248<\/option><option value='Sierra Leone - +232' >Sierra Leone - +232<\/option><option value='Singapore - +65' >Singapore - +65<\/option><option value='Slovakia - +421' >Slovakia - +421<\/option><option value='Slovenia - +386' >Slovenia - +386<\/option><option value='Solomon Islands - +677' >Solomon Islands - +677<\/option><option value='Somalia - +252' >Somalia - +252<\/option><option value='South Africa - +27' >South Africa - +27<\/option><option value='Spain - +34' >Spain - +34<\/option><option value='Sri Lanka - +94' >Sri Lanka - +94<\/option><option value='Sudan - +249' >Sudan - +249<\/option><option value='Sudan, South - +211' >Sudan, South - +211<\/option><option value='Suriname - +597' >Suriname - +597<\/option><option value='Swaziland - +268' >Swaziland - +268<\/option><option value='Sweden - +46' >Sweden - +46<\/option><option value='Switzerland - +41' >Switzerland - +41<\/option><option value='Syria - +963' >Syria - +963<\/option><option value='Taiwan - +886' >Taiwan - +886<\/option><option value='Tajikistan - +992' >Tajikistan - +992<\/option><option value='Tanzania - +255' >Tanzania - +255<\/option><option value='Thailand - +66' >Thailand - +66<\/option><option value='Togo - +228' >Togo - +228<\/option><option value='Tonga - +676' >Tonga - +676<\/option><option value='Trinidad and Tobago - +1-868' >Trinidad and Tobago - +1-868<\/option><option value='Tunisia - +216' >Tunisia - +216<\/option><option value='Turkey - +90' >Turkey - +90<\/option><option value='Turkmenistan - +993' >Turkmenistan - +993<\/option><option value='Tuvalu - +688' >Tuvalu - +688<\/option><option value='Uganda - +256' >Uganda - +256<\/option><option value='Ukraine - +380' >Ukraine - +380<\/option><option value='United Arab Emirates - +971' >United Arab Emirates - +971<\/option><option value='United Kingdom - +44' >United Kingdom - +44<\/option><option value='United States - +1' >United States - +1<\/option><option value='Uruguay - +598' >Uruguay - +598<\/option><option value='Uzbekistan - +998' >Uzbekistan - +998<\/option><option value='Vanuatu - +678' >Vanuatu - +678<\/option><option value='Vatican City - +379' >Vatican City - +379<\/option><option value='Venezuela - +58' >Venezuela - +58<\/option><option value='Vietnam - +84' >Vietnam - +84<\/option><option value='Virgin Islands, British - +1-284' >Virgin Islands, British - +1-284<\/option><option value='Virgin Islands, U.S. - +1-340' >Virgin Islands, U.S. - +1-340<\/option><option value='Yemen - +967' >Yemen - +967<\/option><option value='Zambia - +260' >Zambia - +260<\/option><option value='Zimbabwe - +263' >Zimbabwe - +263<\/option><\/select><\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_inline label_entfernen 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' for='input_6_8'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_6_8' type='tel' value='' class='medium'  placeholder='Enter phone number' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_6_8\"  \/><\/div><div class='gfield_description' id='gfield_description_6_8'>Please include your local area code (without a preceding \"0\")<\/div><\/li><li id=\"field_6_9\" class=\"gfield gfield--type-email gfield--input-type-email 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' >Email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_6_9_container'>\n                                <span id='input_6_9_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_9' id='input_6_9' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_9' class='gform-field-label gform-field-label--type-sub '>E-Mail eingeben<\/label>\n                                <\/span>\n                                <span id='input_6_9_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_9_2' id='input_6_9_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_6_9_2' class='gform-field-label gform-field-label--type-sub '>E-Mail best\u00e4tigen<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_6_11\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Declaration of consent and acknowledgement regarding the General terms of business (GTB) separation of hotel and medical center and regarding any off-label medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_11' tabindex='0'>I have read and understood the <a href=\"https:\/\/oreme.eu\/gtb\/\">General Terms of Business (GTB)<\/a> and hereby confirm that I agree with them.<br \/>\n  <br \/>\nI acknowledge that off-label use of medicinal products may occur in the course of my treatment if there is no satisfactory therapeutic solution for the patient concerned with a preparation already approved for the indication, dosage and use.<br \/>\nAccording to the Swiss Academy of Medical Sciences (SAMS), off-label use is defined as follows:<br \/>\n\"The use of a ready-to-use medicinal product that is authorized in Switzerland or in a country with comparable medicinal product control and whose use deviates from the expert information approved by the competent authorities. This concerns indications, application options, dosage, type of application or the application itself to certain patient groups.\"<br \/>\nOff-label use can only be used if the medical professional treating me has provided me with comprehensive information (about the expected benefits, risks, etc.) and I have given my written consent to the off-label use of medicinal products tailored to my needs.<br \/>\nFinally, I hereby acknowledge that the off-label use of medicinal products is not automatically covered by compulsory health insurance.<br \/>\n<br \/>\nI hereby confirm that I agree to the processing of my data, access to the data by the physician and the transfer of the data to third parties in accordance with the patient information on the following page.<br \/>\nI am aware of possible risks of data exchange of particularly sensitive personal data (possible access by unauthorised third parties in case of insecure communication channels) as well as my rights and give my consent to the mutual contact between my doctor and me as a patient through the contact information given above. Patient information will be shared by the physician's office only through secure communication channels. I agree that administrative requests such as rescheduling appointments will be made using unencrypted e-mail communication (to recipient addresses such as @bluewin.ch, @gmail.com, etc.).<br \/>\nThe Swiss Federal Health Insurance Act (KVG) stipulates that patients receive a copy of the medical bill.<br \/>\n<br \/>\nThe treatment at Privatarztpraxis Rolandas Janu\u0161as OREME follows Swiss law and in the event of a legal dispute, I accept that all legal correspondence would be submitted to the court of CH 9053 Teufen AR, Switzerland. Swiss law would be effective.<br \/>\n<br \/>\n<strong>Patient information on the handling of personal data<\/strong><br \/>\nIn the following, we inform you about the purpose for which the above-mentioned medical practice (hereinafter referred to as medical practice) collects, stores or forwards your personal data. In addition, we inform you about your rights, which you can exercise within the framework of data protection.<br \/>\n<br \/>\n<strong>Responsibilities<\/strong> <br \/>\nThe responsible party for the processing of your personal data and in particular your health data is the medical practice. If you have any questions regarding data protection or if you wish to exercise your rights within the framework of data protection, please contact the practice staff or your doctor directly.<br \/>\n<br \/>\n<strong>Collection and purpose of data processing<\/strong> <br \/>\nThe processing (collection, storage, use and retention) of your data is based on the treatment contract and legal requirements for the fulfillment of the purpose of treatment and the associated obligations. On the one hand, data is collected by the treating physician in the course of your treatment. On the other hand, we also receive data from other physicians and health care professionals with whom you have been or are currently receiving treatment, if you have given your consent for this. In your medical history, only data related to your medical treatment will be processed. The medical history includes the personal information provided on the patient form, such as personal details, contact details and insurance details, as well as, among other things, the educational interview conducted as part of the treatment, collected health data such as medical histories, diagnoses, therapy proposals and findings.<br \/>\n<br \/>\n<strong>Duration of retention<\/strong> <br \/>\nYour medical history will be retained for 20 years after your last treatment. After that, with your express consent, it will be retained or securely deleted or destroyed.<br \/>\n<br \/>\n<strong>Transfer of data<\/strong> <br \/>\nWe will only transfer your personal data, and in particular your medical data, to external third parties if this is permitted or required by law, or if you have consented to the transfer of data as part of your treatment.<br \/>\nThe transfer of data to cantonal and national authorities (e.g. cantonal medical service, health departments, etc.) is based on legal reporting requirements.<br \/>\nOptional: The forwarding of the necessary patient and invoice data to the collection agency takes place for the purpose of collection (collection of due monetary claims).<br \/>\nIn individual cases, depending on your treatment and your corresponding consent, data will be transferred to other authorized recipients (e.g. laboratories, other physicians).<br \/>\n<br \/>\n<strong>Revocation of your consent<\/strong> <br \/>\nIf you have given your express consent for data processing, you may revoke an already given consent in whole or in part at any time. The revocation or the wish to change a consent must be made in writing. As soon as we have received your written revocation and the processing cannot be based on any other legal basis than the consent, the processing will be stopped. The legality of the data processing carried out until the revocation remains unaffected by the revocation.<br \/>\n<br \/>\n<strong>Information, inspection and release<\/strong> <br \/>\nYou have the right to obtain information about your personal data at any time. You can inspect your medical history or request a copy. The issuance of the copy may be subject to a fee. You will be informed in advance of any costs, which will depend on the time and effort required to make the copy.<br \/>\n<br \/>\n<strong>Right to data transfer<\/strong> <br \/>\nYou have the right to have data that we process automatically or digitally handed over to you or to a third party in a common, machine-readable format. This applies in particular to the transfer of medical data to a health professional of your choice. If you request that the data be transferred directly to another responsible party, this will only be done insofar as it is technically feasible.<br \/>\n<br \/>\n<strong>Correction of your data<\/strong><br \/>\nIf you discover or believe that your data is incorrect or incomplete, you have the option of requesting a correction. If neither the correctness nor the incompleteness of your data can be established, you have the option of attaching a denial notice.<\/div><div class='ginput_container ginput_container_consent'><input name='input_11.1' id='input_6_11_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_6_11\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_11_1' >I hereby confirm that I have read, understood and agree with all of the above.<\/label><input type='hidden' name='input_11.2' value='I hereby confirm that I have read, understood and agree with all of the above.' class='gform_hidden' \/><input type='hidden' name='input_11.3' value='14' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_12' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-12' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Financial Policy<\/h2><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-html gfield--input-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\"  >Welcome to OREME. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy that we require you to read and agree to prior to any treatment (Please scroll through and read the entire document!).<\/li><li id=\"field_6_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Financial Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_16' tabindex='0'><strong>REGARDING INSURANCE<\/strong><br \/>\nYour contract for your health insurance has been concluded between you and your insurance company. We are not a contracting party thereto. The services that you receive and the bills you have to pay are part of your agreement exclusively between you and OREME. It is your responsibility to ensure that your bills are paid in full.<\/p><br \/>\n<p>Agreements with insurance companies vary greatly and we expressly point out that not all of them are or will be able to reimburse the costs of our treatment. In order to avoid any misunderstanding or false expectations, we ask you to clarify with your insurance company in advance of your treatment any possibility of cost reimbursement. Please note that some treatments offered by OREME may be considered as not necessary by your insurance company.<br \/>\n<br \/>\n<strong>USUAL AND CUSTOMARY RATES<\/strong><br \/>\nOur pricing is calculated to ensure the highest quality of treatment. The price for a ZOOM consultation is a flat rate of CHF 250. For the in-person consultation patients are charged a flat rate of CHF 400. The costs for additional therapies (i.e. regenerative procedures) will be explained to you in advance thereof.<br \/>\nThe desired consultations and treatments on weekends or during Belgian public holidays are charged with a 300% surcharge.<br \/>\n<br \/>\n<strong>PAYMENT FOR SERVICES<\/strong><br \/>\n(1) The payment for the ZOOM consultation takes place in advance of the consultation.<br \/>\n(2) The payment after the usual consultation is made immediately thereafter.<br \/>\n(3) 50% of the amount set for the procedure is paid at least two weeks in advance. The remaining amount is payable directly after the procedure.<br \/>\nPayments are accepted by PayPal, credit card, cash or by bank transfer with the <strong>name of the patient<\/strong> mentioned in the reference to the following account:<br \/>\n<strong>UBS, IBAN: CH71 0025 4254 2320 0901 R, BIC\/SWIFT: UBSWCHZH80A<br \/>\n<\/strong><br \/>\n<br \/>\n<strong>NO SHOW & LATE CANCELLATION<\/strong><br \/>\n<strong>Consultation cancelation fee:<\/strong><br \/>\nOur financial policy requires 48 hours notice if you are unable to make your appointment. If no notice or less than 48 hours\u2019 notice is given, there will be a CHF 250 fee for consultation.<br \/>\n<strong>Treatment cancelation fee:<\/strong><br \/>\nFrom 21 days prior to the procedure date and onwards: 50% of the treatment price will be charged as a cancelation fee.<br \/>\n<br \/>\n<strong>This payment arrangement will be valid for six (6) months  from today\u2019s date.<\/strong><\/div><div class='ginput_container ginput_container_consent'><input name='input_16.1' id='input_6_16_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_6_16\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_16_1' >I have read the Financial Policy. I understand and agree to this Financial Policy.<\/label><input type='hidden' name='input_16.2' value='I have read the Financial Policy. I understand and agree to this Financial Policy.' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='14' class='gform_hidden' \/><\/div><\/li><li id=\"field_6_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is there anyone involved in your care, or payment of your care with whom we may share your medical information?<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_6_22'>\n\t\t\t<li class='gchoice gchoice_6_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_6_22_0'    \/>\n\t\t\t\t<label for='choice_6_22_0' id='label_6_22_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_6_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_6_22_1'    \/>\n\t\t\t\t<label for='choice_6_22_1' id='label_6_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_19\" class=\"gfield gfield--type-name gfield--input-type-name 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 gfield_label_before_complex' >Entrusted Person&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_19'>\n                            \n                            <span id='input_6_19_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.3' id='input_6_19_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_19_3' class='gform-field-label gform-field-label--type-sub '>Vorname<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_19_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_19.6' id='input_6_19_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_19_6' class='gform-field-label gform-field-label--type-sub '>Nachname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_20\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_6_20'>Entrusted Person&#039;s Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_6_20' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_240\" class=\"gfield gfield--type-text gfield--input-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_6_240'>Entrusted person&#039;s relationship to patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_240' id='input_6_240' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Patient Record of Disclosures &amp; Coordination of Care<\/h2><\/li><li id=\"field_6_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 representing the patient as his or her authorized legal representative or legal guardian?<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_6_56'>\n\t\t\t<li class='gchoice gchoice_6_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_6_56_0'    \/>\n\t\t\t\t<label for='choice_6_56_0' id='label_6_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_6_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='No, I am representing myself'  id='choice_6_56_1'    \/>\n\t\t\t\t<label for='choice_6_56_1' id='label_6_56_1' class='gform-field-label gform-field-label--type-inline'>No, I am representing myself<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_57\" class=\"gfield gfield--type-html gfield--input-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\"  >Please enter your name and relationship to the patient<\/li><li id=\"field_6_58\" class=\"gfield gfield--type-name gfield--input-type-name 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 gfield_label_before_complex' >Representative&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_58'>\n                            \n                            <span id='input_6_58_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.3' id='input_6_58_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_58_3' class='gform-field-label gform-field-label--type-sub '>Vorname<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_58_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_58.6' id='input_6_58_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_58_6' class='gform-field-label gform-field-label--type-sub '>Nachname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_59\" class=\"gfield gfield--type-text gfield--input-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_6_59'>Representative&#039;s Relationship to Patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_6_59' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_410\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Referral Information<\/h2><\/li><li id=\"field_6_411\" class=\"gfield gfield--type-select gfield--input-type-select 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_6_411'>Please tell us how you found out about Oreme<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_411' id='input_6_411' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='AI' >AI<\/option><option value='internet \/ search engine' >internet \/ search engine<\/option><option value='social media' >social media<\/option><option value='employer' >employer<\/option><option value='friend or relative' >friend or relative<\/option><option value='other Oreme patient' >other Oreme patient<\/option><option value='magazine article' >magazine article<\/option><option value='YouTube' >YouTube<\/option><option value='other source' >other source<\/option><\/select><\/div><\/li><li id=\"field_6_412\" class=\"gfield gfield--type-text gfield--input-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_6_412'>Any source in particular?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_412' id='input_6_412' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_55' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Current Affliction<\/h2><\/li><li id=\"field_6_65\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gf_hide_charleft 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_6_65'>Your height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_6_65' type='text' value='' class='small' maxlength='3'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_66\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gf_hide_charleft 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_6_66'>Your weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_6_66' type='text' value='' class='small' maxlength='3'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_60\" class=\"gfield gfield--type-html gfield--input-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\"  >The following questions are about how your illness is affecting you now. <strong>Please indicate where your pain is on the drawing below.<\/strong> <\/li><li id=\"field_6_239\" class=\"gfield gfield--type-text gfield--input-type-text exclude field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_239'>Image prepend<\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_6_239' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_238\" class=\"gfield gfield--type-post_image gfield--input-type-post_image patient-image field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_238'>Patient image<\/label><div class='ginput_complex ginput_container ginput_container_post_image gform-grid-row'><span class='ginput_full gform-grid-col'><input name='input_238' id='input_6_238' type='file' class='medium'   aria-invalid=\"false\" aria-describedby=\"extensions_message_6_238\" \/><span id='extensions_message_6_238' class='gfield_description gform_fileupload_rules'>Akzeptierte Datentypen: jpg, jpeg, png, gif.<\/span><\/span><\/div><\/li><li id=\"field_6_61\" class=\"gfield gfield--type-html gfield--input-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 class=\"image-handle-click-container\"><canvas id=\"canvas\" width=\"824\" height=\"767\"><\/canvas><div class=\"canvas-erase\">Erase all points and start again<\/div><\/div><\/li><li id=\"field_6_62\" class=\"gfield gfield--type-html gfield--input-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\"  >List your pain and problems in order of severity (most severe first):<\/li><li id=\"field_6_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_63'>1.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_6_63' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_413\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other pain or problem?<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_6_413'>\n\t\t\t<li class='gchoice gchoice_6_413_0'>\n\t\t\t\t<input name='input_413' type='radio' value='Yes'  id='choice_6_413_0'    \/>\n\t\t\t\t<label for='choice_6_413_0' id='label_6_413_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_6_413_1'>\n\t\t\t\t<input name='input_413' type='radio' value='No'  id='choice_6_413_1'    \/>\n\t\t\t\t<label for='choice_6_413_1' id='label_6_413_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_69'>2.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_6_69' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_414\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other pain or problem?<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_6_414'>\n\t\t\t<li class='gchoice gchoice_6_414_0'>\n\t\t\t\t<input name='input_414' type='radio' value='Yes'  id='choice_6_414_0'    \/>\n\t\t\t\t<label for='choice_6_414_0' id='label_6_414_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_6_414_1'>\n\t\t\t\t<input name='input_414' type='radio' value='No'  id='choice_6_414_1'    \/>\n\t\t\t\t<label for='choice_6_414_1' id='label_6_414_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_68'>3.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_6_68' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_415\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other pain or problem?<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_6_415'>\n\t\t\t<li class='gchoice gchoice_6_415_0'>\n\t\t\t\t<input name='input_415' type='radio' value='Yes'  id='choice_6_415_0'    \/>\n\t\t\t\t<label for='choice_6_415_0' id='label_6_415_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_6_415_1'>\n\t\t\t\t<input name='input_415' type='radio' value='No'  id='choice_6_415_1'    \/>\n\t\t\t\t<label for='choice_6_415_1' id='label_6_415_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_67'>4.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_6_67' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_70\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_6_70'>Please describe how your illnesses and pain began:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_6_70' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Since the injury or when your problem began, your symptoms are<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_6_71'>\n\t\t\t<li class='gchoice gchoice_6_71_0'>\n\t\t\t\t<input name='input_71' type='radio' value='Better'  id='choice_6_71_0'    \/>\n\t\t\t\t<label for='choice_6_71_0' id='label_6_71_0' class='gform-field-label gform-field-label--type-inline'>Better<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_71_1'>\n\t\t\t\t<input name='input_71' type='radio' value='Worse'  id='choice_6_71_1'    \/>\n\t\t\t\t<label for='choice_6_71_1' id='label_6_71_1' class='gform-field-label gform-field-label--type-inline'>Worse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_71_2'>\n\t\t\t\t<input name='input_71' type='radio' value='Unchanged'  id='choice_6_71_2'    \/>\n\t\t\t\t<label for='choice_6_71_2' id='label_6_71_2' class='gform-field-label gform-field-label--type-inline'>Unchanged<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >At this time are your symptoms:<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_6_72'>\n\t\t\t<li class='gchoice gchoice_6_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Better'  id='choice_6_72_0'    \/>\n\t\t\t\t<label for='choice_6_72_0' id='label_6_72_0' class='gform-field-label gform-field-label--type-inline'>Better<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Improving'  id='choice_6_72_1'    \/>\n\t\t\t\t<label for='choice_6_72_1' id='label_6_72_1' class='gform-field-label gform-field-label--type-inline'>Improving<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_72_2'>\n\t\t\t\t<input name='input_72' type='radio' value='Getting Worse'  id='choice_6_72_2'    \/>\n\t\t\t\t<label for='choice_6_72_2' id='label_6_72_2' class='gform-field-label gform-field-label--type-inline'>Getting Worse<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_72_3'>\n\t\t\t\t<input name='input_72' type='radio' value='Unchanged'  id='choice_6_72_3'    \/>\n\t\t\t\t<label for='choice_6_72_3' id='label_6_72_3' class='gform-field-label gform-field-label--type-inline'>Unchanged<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_73\" class=\"gfield gfield--type-text gfield--input-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_6_73'>Is there anything that INCREASES your pain\/symptoms?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_6_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_74\" class=\"gfield gfield--type-text gfield--input-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_6_74'>Is there anything that RELIEVES your pain\/symptoms?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_6_74' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_80\" class=\"gfield gfield--type-html gfield--input-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\"  >Select the circle that describes<\/li><li id=\"field_6_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Your pain as it usually feels<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_6_75'>\n\t\t\t<li class='gchoice gchoice_6_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='0 None'  id='choice_6_75_0'    \/>\n\t\t\t\t<label for='choice_6_75_0' id='label_6_75_0' class='gform-field-label gform-field-label--type-inline'>0 None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='1-2 Mild'  id='choice_6_75_1'    \/>\n\t\t\t\t<label for='choice_6_75_1' id='label_6_75_1' class='gform-field-label gform-field-label--type-inline'>1-2 Mild<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_75_2'>\n\t\t\t\t<input name='input_75' type='radio' value='3-4 Uncomfortable'  id='choice_6_75_2'    \/>\n\t\t\t\t<label for='choice_6_75_2' id='label_6_75_2' class='gform-field-label gform-field-label--type-inline'>3-4 Uncomfortable<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_75_3'>\n\t\t\t\t<input name='input_75' type='radio' value='5-6 Distressing (fairly severe)'  id='choice_6_75_3'    \/>\n\t\t\t\t<label for='choice_6_75_3' id='label_6_75_3' class='gform-field-label gform-field-label--type-inline'>5-6 Distressing (fairly severe)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_75_4'>\n\t\t\t\t<input name='input_75' type='radio' value='7-8 Very severe (horrible)'  id='choice_6_75_4'    \/>\n\t\t\t\t<label for='choice_6_75_4' id='label_6_75_4' class='gform-field-label gform-field-label--type-inline'>7-8 Very severe (horrible)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_75_5'>\n\t\t\t\t<input name='input_75' type='radio' value='9-10 Unbearable (excruciating)'  id='choice_6_75_5'    \/>\n\t\t\t\t<label for='choice_6_75_5' id='label_6_75_5' class='gform-field-label gform-field-label--type-inline'>9-10 Unbearable (excruciating)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Your pain as it is right now<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_6_77'>\n\t\t\t<li class='gchoice gchoice_6_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='0 None'  id='choice_6_77_0'    \/>\n\t\t\t\t<label for='choice_6_77_0' id='label_6_77_0' class='gform-field-label gform-field-label--type-inline'>0 None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='1-2 Mild'  id='choice_6_77_1'    \/>\n\t\t\t\t<label for='choice_6_77_1' id='label_6_77_1' class='gform-field-label gform-field-label--type-inline'>1-2 Mild<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_77_2'>\n\t\t\t\t<input name='input_77' type='radio' value='3-4 Uncomfortable'  id='choice_6_77_2'    \/>\n\t\t\t\t<label for='choice_6_77_2' id='label_6_77_2' class='gform-field-label gform-field-label--type-inline'>3-4 Uncomfortable<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_77_3'>\n\t\t\t\t<input name='input_77' type='radio' value='5-6 Distressing (fairly severe)'  id='choice_6_77_3'    \/>\n\t\t\t\t<label for='choice_6_77_3' id='label_6_77_3' class='gform-field-label gform-field-label--type-inline'>5-6 Distressing (fairly severe)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_77_4'>\n\t\t\t\t<input name='input_77' type='radio' value='7-8 Very severe (horrible)'  id='choice_6_77_4'    \/>\n\t\t\t\t<label for='choice_6_77_4' id='label_6_77_4' class='gform-field-label gform-field-label--type-inline'>7-8 Very severe (horrible)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_77_5'>\n\t\t\t\t<input name='input_77' type='radio' value='9-10 Unbearable (excruciating)'  id='choice_6_77_5'    \/>\n\t\t\t\t<label for='choice_6_77_5' id='label_6_77_5' class='gform-field-label gform-field-label--type-inline'>9-10 Unbearable (excruciating)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Your pain at it\u2019s worst<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_6_78'>\n\t\t\t<li class='gchoice gchoice_6_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='0 None'  id='choice_6_78_0'    \/>\n\t\t\t\t<label for='choice_6_78_0' id='label_6_78_0' class='gform-field-label gform-field-label--type-inline'>0 None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='1-2 Mild'  id='choice_6_78_1'    \/>\n\t\t\t\t<label for='choice_6_78_1' id='label_6_78_1' class='gform-field-label gform-field-label--type-inline'>1-2 Mild<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='3-4 Uncomfortable'  id='choice_6_78_2'    \/>\n\t\t\t\t<label for='choice_6_78_2' id='label_6_78_2' class='gform-field-label gform-field-label--type-inline'>3-4 Uncomfortable<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_78_3'>\n\t\t\t\t<input name='input_78' type='radio' value='5-6 Distressing (fairly severe)'  id='choice_6_78_3'    \/>\n\t\t\t\t<label for='choice_6_78_3' id='label_6_78_3' class='gform-field-label gform-field-label--type-inline'>5-6 Distressing (fairly severe)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_78_4'>\n\t\t\t\t<input name='input_78' type='radio' value='7-8 Very severe (horrible)'  id='choice_6_78_4'    \/>\n\t\t\t\t<label for='choice_6_78_4' id='label_6_78_4' class='gform-field-label gform-field-label--type-inline'>7-8 Very severe (horrible)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_78_5'>\n\t\t\t\t<input name='input_78' type='radio' value='9-10 Unbearable (excruciating)'  id='choice_6_78_5'    \/>\n\t\t\t\t<label for='choice_6_78_5' id='label_6_78_5' class='gform-field-label gform-field-label--type-inline'>9-10 Unbearable (excruciating)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Your pain when it hurts the least<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_6_79'>\n\t\t\t<li class='gchoice gchoice_6_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='0 None'  id='choice_6_79_0'    \/>\n\t\t\t\t<label for='choice_6_79_0' id='label_6_79_0' class='gform-field-label gform-field-label--type-inline'>0 None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='1-2 Mild'  id='choice_6_79_1'    \/>\n\t\t\t\t<label for='choice_6_79_1' id='label_6_79_1' class='gform-field-label gform-field-label--type-inline'>1-2 Mild<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_79_2'>\n\t\t\t\t<input name='input_79' type='radio' value='3-4 Uncomfortable'  id='choice_6_79_2'    \/>\n\t\t\t\t<label for='choice_6_79_2' id='label_6_79_2' class='gform-field-label gform-field-label--type-inline'>3-4 Uncomfortable<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_79_3'>\n\t\t\t\t<input name='input_79' type='radio' value='5-6 Distressing (fairly severe)'  id='choice_6_79_3'    \/>\n\t\t\t\t<label for='choice_6_79_3' id='label_6_79_3' class='gform-field-label gform-field-label--type-inline'>5-6 Distressing (fairly severe)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_79_4'>\n\t\t\t\t<input name='input_79' type='radio' value='7-8 Very severe (horrible)'  id='choice_6_79_4'    \/>\n\t\t\t\t<label for='choice_6_79_4' id='label_6_79_4' class='gform-field-label gform-field-label--type-inline'>7-8 Very severe (horrible)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_79_5'>\n\t\t\t\t<input name='input_79' type='radio' value='9-10 Unbearable (excruciating)'  id='choice_6_79_5'    \/>\n\t\t\t\t<label for='choice_6_79_5' id='label_6_79_5' class='gform-field-label gform-field-label--type-inline'>9-10 Unbearable (excruciating)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >How many days a week do you experience pain?<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_6_81'>\n\t\t\t<li class='gchoice gchoice_6_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Daily'  id='choice_6_81_0'    \/>\n\t\t\t\t<label for='choice_6_81_0' id='label_6_81_0' class='gform-field-label gform-field-label--type-inline'>Daily<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='1-2'  id='choice_6_81_1'    \/>\n\t\t\t\t<label for='choice_6_81_1' id='label_6_81_1' class='gform-field-label gform-field-label--type-inline'>1-2<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='3-4'  id='choice_6_81_2'    \/>\n\t\t\t\t<label for='choice_6_81_2' id='label_6_81_2' class='gform-field-label gform-field-label--type-inline'>3-4<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_81_3'>\n\t\t\t\t<input name='input_81' type='radio' value='5-6'  id='choice_6_81_3'    \/>\n\t\t\t\t<label for='choice_6_81_3' id='label_6_81_3' class='gform-field-label gform-field-label--type-inline'>5-6<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_81_4'>\n\t\t\t\t<input name='input_81' type='radio' value='Intermittently'  id='choice_6_81_4'    \/>\n\t\t\t\t<label for='choice_6_81_4' id='label_6_81_4' class='gform-field-label gform-field-label--type-inline'>Intermittently<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_82' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_82' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_5' class='gform_page' data-js='page-field-id-82' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_83\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Past Medical History<\/h2><div class='gsection_description' id='gfield_description_6_83'>(Current medical problems such as diabetes, hypertension or high cholesterol)<\/div><\/li><li id=\"field_6_416\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 medical 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_6_416'>\n\t\t\t<li class='gchoice gchoice_6_416_0'>\n\t\t\t\t<input name='input_416' type='radio' value='Yes'  id='choice_6_416_0'    \/>\n\t\t\t\t<label for='choice_6_416_0' id='label_6_416_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_6_416_1'>\n\t\t\t\t<input name='input_416' type='radio' value='No'  id='choice_6_416_1'    \/>\n\t\t\t\t<label for='choice_6_416_1' id='label_6_416_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_263\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">1. Medical problem<\/h2><\/li><li id=\"field_6_86\" class=\"gfield gfield--type-text gfield--input-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_6_86'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_6_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_87\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_87'>Treating Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_6_87' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medical problem?<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_6_244'>\n\t\t\t<li class='gchoice gchoice_6_244_0'>\n\t\t\t\t<input name='input_244' type='radio' value='Yes'  id='choice_6_244_0'    \/>\n\t\t\t\t<label for='choice_6_244_0' id='label_6_244_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_6_244_1'>\n\t\t\t\t<input name='input_244' type='radio' value='No'  id='choice_6_244_1'    \/>\n\t\t\t\t<label for='choice_6_244_1' id='label_6_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_264\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">2. Medical problem<\/h2><\/li><li id=\"field_6_90\" class=\"gfield gfield--type-text gfield--input-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_6_90'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_6_90' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_91\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_91'>Treating Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_6_91' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_245\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medical problem?<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_6_245'>\n\t\t\t<li class='gchoice gchoice_6_245_0'>\n\t\t\t\t<input name='input_245' type='radio' value='Yes'  id='choice_6_245_0'    \/>\n\t\t\t\t<label for='choice_6_245_0' id='label_6_245_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_6_245_1'>\n\t\t\t\t<input name='input_245' type='radio' value='No'  id='choice_6_245_1'    \/>\n\t\t\t\t<label for='choice_6_245_1' id='label_6_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_265\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">3. Medical problem<\/h2><\/li><li id=\"field_6_94\" class=\"gfield gfield--type-text gfield--input-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_6_94'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_6_94' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_95\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_95'>Treating Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_6_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_246\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medical problem?<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_6_246'>\n\t\t\t<li class='gchoice gchoice_6_246_0'>\n\t\t\t\t<input name='input_246' type='radio' value='Yes'  id='choice_6_246_0'    \/>\n\t\t\t\t<label for='choice_6_246_0' id='label_6_246_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_6_246_1'>\n\t\t\t\t<input name='input_246' type='radio' value='No'  id='choice_6_246_1'    \/>\n\t\t\t\t<label for='choice_6_246_1' id='label_6_246_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_266\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">4. Medical problem<\/h2><\/li><li id=\"field_6_98\" class=\"gfield gfield--type-text gfield--input-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_6_98'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_6_98' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_99\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_99'>Treating Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_6_99' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medical problem?<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_6_247'>\n\t\t\t<li class='gchoice gchoice_6_247_0'>\n\t\t\t\t<input name='input_247' type='radio' value='Yes'  id='choice_6_247_0'    \/>\n\t\t\t\t<label for='choice_6_247_0' id='label_6_247_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_6_247_1'>\n\t\t\t\t<input name='input_247' type='radio' value='No'  id='choice_6_247_1'    \/>\n\t\t\t\t<label for='choice_6_247_1' id='label_6_247_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_267\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">5. Medical problem<\/h2><\/li><li id=\"field_6_102\" class=\"gfield gfield--type-text gfield--input-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_6_102'>Diagnosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_6_102' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_103\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_103'>Treating Physician<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_6_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_104\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Previous Trauma<\/h2><div class='gsection_description' id='gfield_description_6_104'>(Automobile accident, fractures, strains, any other)<\/div><\/li><li id=\"field_6_417\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 previous traumas?<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_6_417'>\n\t\t\t<li class='gchoice gchoice_6_417_0'>\n\t\t\t\t<input name='input_417' type='radio' value='Yes'  id='choice_6_417_0'    \/>\n\t\t\t\t<label for='choice_6_417_0' id='label_6_417_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_6_417_1'>\n\t\t\t\t<input name='input_417' type='radio' value='No'  id='choice_6_417_1'    \/>\n\t\t\t\t<label for='choice_6_417_1' id='label_6_417_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_268\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">1. Trauma<\/h2><\/li><li id=\"field_6_421\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_421'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_421' id='input_6_421' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_108\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_108'>Injury\/Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_6_108' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_109\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_109'>Remaining Problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_6_109' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_241\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other trauma?<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_6_241'>\n\t\t\t<li class='gchoice gchoice_6_241_0'>\n\t\t\t\t<input name='input_241' type='radio' value='Yes'  id='choice_6_241_0'    \/>\n\t\t\t\t<label for='choice_6_241_0' id='label_6_241_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_6_241_1'>\n\t\t\t\t<input name='input_241' type='radio' value='No'  id='choice_6_241_1'    \/>\n\t\t\t\t<label for='choice_6_241_1' id='label_6_241_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_269\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">2. Trauma<\/h2><\/li><li id=\"field_6_422\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_422'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_422' id='input_6_422' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_113\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_113'>Injury\/Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_6_113' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_114\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_114'>Remaining Problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_6_114' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_242\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other trauma?<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_6_242'>\n\t\t\t<li class='gchoice gchoice_6_242_0'>\n\t\t\t\t<input name='input_242' type='radio' value='Yes'  id='choice_6_242_0'    \/>\n\t\t\t\t<label for='choice_6_242_0' id='label_6_242_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_6_242_1'>\n\t\t\t\t<input name='input_242' type='radio' value='No'  id='choice_6_242_1'    \/>\n\t\t\t\t<label for='choice_6_242_1' id='label_6_242_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_270\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">3. Trauma<\/h2><\/li><li id=\"field_6_423\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_423'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_423' id='input_6_423' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_118\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_118'>Injury\/Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_6_118' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_119\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_119'>Remaining Problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_6_119' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_243\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other trauma?<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_6_243'>\n\t\t\t<li class='gchoice gchoice_6_243_0'>\n\t\t\t\t<input name='input_243' type='radio' value='Yes'  id='choice_6_243_0'    \/>\n\t\t\t\t<label for='choice_6_243_0' id='label_6_243_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_6_243_1'>\n\t\t\t\t<input name='input_243' type='radio' value='No'  id='choice_6_243_1'    \/>\n\t\t\t\t<label for='choice_6_243_1' id='label_6_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_271\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">4. Trauma<\/h2><\/li><li id=\"field_6_424\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_424'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_424' id='input_6_424' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_123\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_123'>Injury\/Accident<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_6_123' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_124\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_124'>Remaining Problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_6_124' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_125\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Allergies<\/h2><\/li><li id=\"field_6_418\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 allergies (medication or environmental)?<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_6_418'>\n\t\t\t<li class='gchoice gchoice_6_418_0'>\n\t\t\t\t<input name='input_418' type='radio' value='Yes'  id='choice_6_418_0'    \/>\n\t\t\t\t<label for='choice_6_418_0' id='label_6_418_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_6_418_1'>\n\t\t\t\t<input name='input_418' type='radio' value='No'  id='choice_6_418_1'    \/>\n\t\t\t\t<label for='choice_6_418_1' id='label_6_418_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_126\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_6_126'>Please describe them in detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_6_126' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Medication and Supplements<\/h2><div class='gsection_description' id='gfield_description_6_127'>(please note all medications you take \u2013 even if only occasionally)<\/div><\/li><li id=\"field_6_419\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 supplements?<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_6_419'>\n\t\t\t<li class='gchoice gchoice_6_419_0'>\n\t\t\t\t<input name='input_419' type='radio' value='Yes'  id='choice_6_419_0'    \/>\n\t\t\t\t<label for='choice_6_419_0' id='label_6_419_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_6_419_1'>\n\t\t\t\t<input name='input_419' type='radio' value='No'  id='choice_6_419_1'    \/>\n\t\t\t\t<label for='choice_6_419_1' id='label_6_419_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_272\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">1. Medication<\/h2><\/li><li id=\"field_6_130\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_130'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_6_130' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_131\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_131'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_6_131' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_132\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_132'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_6_132' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_425\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_425'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_425' id='input_6_425' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_136\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_136'>Why?<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_6_136' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_248\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_248'>\n\t\t\t<li class='gchoice gchoice_6_248_0'>\n\t\t\t\t<input name='input_248' type='radio' value='Yes'  id='choice_6_248_0'    \/>\n\t\t\t\t<label for='choice_6_248_0' id='label_6_248_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_6_248_1'>\n\t\t\t\t<input name='input_248' type='radio' value='No'  id='choice_6_248_1'    \/>\n\t\t\t\t<label for='choice_6_248_1' id='label_6_248_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_273\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">2. Medication<\/h2><\/li><li id=\"field_6_151\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_151'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_6_151' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_152\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_152'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_6_152' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_153\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_153'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_6_153' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_426\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_426'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_426' id='input_6_426' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_155\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_155'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_6_155' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_249\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_249'>\n\t\t\t<li class='gchoice gchoice_6_249_0'>\n\t\t\t\t<input name='input_249' type='radio' value='Yes'  id='choice_6_249_0'    \/>\n\t\t\t\t<label for='choice_6_249_0' id='label_6_249_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_6_249_1'>\n\t\t\t\t<input name='input_249' type='radio' value='No'  id='choice_6_249_1'    \/>\n\t\t\t\t<label for='choice_6_249_1' id='label_6_249_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_274\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">3. Medication<\/h2><\/li><li id=\"field_6_156\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_156'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_6_156' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_157\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_157'>Dose<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_6_157' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_158\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_158'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_6_158' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_427\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_427'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_427' id='input_6_427' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_160\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_160'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_6_160' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_250\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_250'>\n\t\t\t<li class='gchoice gchoice_6_250_0'>\n\t\t\t\t<input name='input_250' type='radio' value='Yes'  id='choice_6_250_0'    \/>\n\t\t\t\t<label for='choice_6_250_0' id='label_6_250_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_6_250_1'>\n\t\t\t\t<input name='input_250' type='radio' value='No'  id='choice_6_250_1'    \/>\n\t\t\t\t<label for='choice_6_250_1' id='label_6_250_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_275\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">4. Medication<\/h2><\/li><li id=\"field_6_161\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_161'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_6_161' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_162\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_162'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_6_162' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_163\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_163'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_6_163' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_428\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_428'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_428' id='input_6_428' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_165\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_165'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_6_165' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_251\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_251'>\n\t\t\t<li class='gchoice gchoice_6_251_0'>\n\t\t\t\t<input name='input_251' type='radio' value='Yes'  id='choice_6_251_0'    \/>\n\t\t\t\t<label for='choice_6_251_0' id='label_6_251_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_6_251_1'>\n\t\t\t\t<input name='input_251' type='radio' value='No'  id='choice_6_251_1'    \/>\n\t\t\t\t<label for='choice_6_251_1' id='label_6_251_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_276\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">5. Medication<\/h2><\/li><li id=\"field_6_166\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_166'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_6_166' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_167\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_167'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_6_167' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_168\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_168'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_6_168' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_429\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_429'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_429' id='input_6_429' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_170\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_170'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_6_170' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_252'>\n\t\t\t<li class='gchoice gchoice_6_252_0'>\n\t\t\t\t<input name='input_252' type='radio' value='Yes'  id='choice_6_252_0'    \/>\n\t\t\t\t<label for='choice_6_252_0' id='label_6_252_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_6_252_1'>\n\t\t\t\t<input name='input_252' type='radio' value='No'  id='choice_6_252_1'    \/>\n\t\t\t\t<label for='choice_6_252_1' id='label_6_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_277\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">6. Medication<\/h2><\/li><li id=\"field_6_171\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_171'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_6_171' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_172\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_172'>Dose<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_6_172' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_173\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_173'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_6_173' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_430\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_430'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_430' id='input_6_430' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_175\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_175'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_6_175' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_253\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_253'>\n\t\t\t<li class='gchoice gchoice_6_253_0'>\n\t\t\t\t<input name='input_253' type='radio' value='Yes'  id='choice_6_253_0'    \/>\n\t\t\t\t<label for='choice_6_253_0' id='label_6_253_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_6_253_1'>\n\t\t\t\t<input name='input_253' type='radio' value='No'  id='choice_6_253_1'    \/>\n\t\t\t\t<label for='choice_6_253_1' id='label_6_253_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_278\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">7. Medication<\/h2><\/li><li id=\"field_6_177\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_177'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_6_177' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_178\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_178'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_6_178' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_179\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_179'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_6_179' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_431\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_431'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_431' id='input_6_431' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_181\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_181'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_6_181' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_254\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other medication?<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_6_254'>\n\t\t\t<li class='gchoice gchoice_6_254_0'>\n\t\t\t\t<input name='input_254' type='radio' value='Yes'  id='choice_6_254_0'    \/>\n\t\t\t\t<label for='choice_6_254_0' id='label_6_254_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_6_254_1'>\n\t\t\t\t<input name='input_254' type='radio' value='No'  id='choice_6_254_1'    \/>\n\t\t\t\t<label for='choice_6_254_1' id='label_6_254_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_279\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">8. Medication<\/h2><\/li><li id=\"field_6_182\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_182'>Medication<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_6_182' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_183\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_183'>Dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_6_183' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_184\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_184'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_6_184' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_432\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_432'>Since when?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_432' id='input_6_432' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_186\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_186'>Why?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_6_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_187\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Surgical History<\/h2><\/li><li id=\"field_6_420\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 any surgery?<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_6_420'>\n\t\t\t<li class='gchoice gchoice_6_420_0'>\n\t\t\t\t<input name='input_420' type='radio' value='Yes'  id='choice_6_420_0'    \/>\n\t\t\t\t<label for='choice_6_420_0' id='label_6_420_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_6_420_1'>\n\t\t\t\t<input name='input_420' type='radio' value='No'  id='choice_6_420_1'    \/>\n\t\t\t\t<label for='choice_6_420_1' id='label_6_420_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_285\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">1. Surgery<\/h2><\/li><li id=\"field_6_190\" class=\"gfield gfield--type-text gfield--input-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_6_190'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_6_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_191\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_191'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_6_191' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_433\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_433'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_433' id='input_6_433' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_280\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other surgery?<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_6_280'>\n\t\t\t<li class='gchoice gchoice_6_280_0'>\n\t\t\t\t<input name='input_280' type='radio' value='Yes'  id='choice_6_280_0'    \/>\n\t\t\t\t<label for='choice_6_280_0' id='label_6_280_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_6_280_1'>\n\t\t\t\t<input name='input_280' type='radio' value='No'  id='choice_6_280_1'    \/>\n\t\t\t\t<label for='choice_6_280_1' id='label_6_280_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_286\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">2. Surgery<\/h2><\/li><li id=\"field_6_203\" class=\"gfield gfield--type-text gfield--input-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_6_203'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_6_203' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_204\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_204'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_6_204' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_434\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_434'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_434' id='input_6_434' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_281\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other surgery?<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_6_281'>\n\t\t\t<li class='gchoice gchoice_6_281_0'>\n\t\t\t\t<input name='input_281' type='radio' value='Yes'  id='choice_6_281_0'    \/>\n\t\t\t\t<label for='choice_6_281_0' id='label_6_281_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_6_281_1'>\n\t\t\t\t<input name='input_281' type='radio' value='No'  id='choice_6_281_1'    \/>\n\t\t\t\t<label for='choice_6_281_1' id='label_6_281_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_287\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">3. Surgery<\/h2><\/li><li id=\"field_6_206\" class=\"gfield gfield--type-text gfield--input-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_6_206'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_6_206' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_207\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_207'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_6_207' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_435\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_435'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_435' id='input_6_435' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_282\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other surgery?<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_6_282'>\n\t\t\t<li class='gchoice gchoice_6_282_0'>\n\t\t\t\t<input name='input_282' type='radio' value='Yes'  id='choice_6_282_0'    \/>\n\t\t\t\t<label for='choice_6_282_0' id='label_6_282_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_6_282_1'>\n\t\t\t\t<input name='input_282' type='radio' value='No'  id='choice_6_282_1'    \/>\n\t\t\t\t<label for='choice_6_282_1' id='label_6_282_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_288\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">4. Surgery<\/h2><\/li><li id=\"field_6_209\" class=\"gfield gfield--type-text gfield--input-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_6_209'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_6_209' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_210\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_210'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_6_210' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_436\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_436'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_436' id='input_6_436' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_283\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other surgery?<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_6_283'>\n\t\t\t<li class='gchoice gchoice_6_283_0'>\n\t\t\t\t<input name='input_283' type='radio' value='Yes'  id='choice_6_283_0'    \/>\n\t\t\t\t<label for='choice_6_283_0' id='label_6_283_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_6_283_1'>\n\t\t\t\t<input name='input_283' type='radio' value='No'  id='choice_6_283_1'    \/>\n\t\t\t\t<label for='choice_6_283_1' id='label_6_283_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_289\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">5. Surgery<\/h2><\/li><li id=\"field_6_212\" class=\"gfield gfield--type-text gfield--input-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_6_212'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_212' id='input_6_212' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_213\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_213'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_213' id='input_6_213' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_437\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_437'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_437' id='input_6_437' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_284\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Any other surgery?<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_6_284'>\n\t\t\t<li class='gchoice gchoice_6_284_0'>\n\t\t\t\t<input name='input_284' type='radio' value='Yes'  id='choice_6_284_0'    \/>\n\t\t\t\t<label for='choice_6_284_0' id='label_6_284_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_6_284_1'>\n\t\t\t\t<input name='input_284' type='radio' value='No'  id='choice_6_284_1'    \/>\n\t\t\t\t<label for='choice_6_284_1' id='label_6_284_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_290\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">6. Surgery<\/h2><\/li><li id=\"field_6_215\" class=\"gfield gfield--type-text gfield--input-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_6_215'>Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_215' id='input_6_215' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_216\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_216'>Surgeon<\/label><div class='ginput_container ginput_container_text'><input name='input_216' id='input_6_216' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_438\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_438'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_438' id='input_6_438' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_218\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Family History<\/h2><\/li><li id=\"field_6_219\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Disability<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_6_219'>\n\t\t\t<li class='gchoice gchoice_6_219_0'>\n\t\t\t\t<input name='input_219' type='radio' value='Yes'  id='choice_6_219_0'    \/>\n\t\t\t\t<label for='choice_6_219_0' id='label_6_219_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_6_219_1'>\n\t\t\t\t<input name='input_219' type='radio' value='No'  id='choice_6_219_1'    \/>\n\t\t\t\t<label for='choice_6_219_1' id='label_6_219_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_220\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Alcoholism<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_6_220'>\n\t\t\t<li class='gchoice gchoice_6_220_0'>\n\t\t\t\t<input name='input_220' type='radio' value='Yes'  id='choice_6_220_0'    \/>\n\t\t\t\t<label for='choice_6_220_0' id='label_6_220_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_6_220_1'>\n\t\t\t\t<input name='input_220' type='radio' value='No'  id='choice_6_220_1'    \/>\n\t\t\t\t<label for='choice_6_220_1' id='label_6_220_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_221'>\n\t\t\t<li class='gchoice gchoice_6_221_0'>\n\t\t\t\t<input name='input_221' type='radio' value='Yes'  id='choice_6_221_0'    \/>\n\t\t\t\t<label for='choice_6_221_0' id='label_6_221_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_6_221_1'>\n\t\t\t\t<input name='input_221' type='radio' value='No'  id='choice_6_221_1'    \/>\n\t\t\t\t<label for='choice_6_221_1' id='label_6_221_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_222\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rheumatoid 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_6_222'>\n\t\t\t<li class='gchoice gchoice_6_222_0'>\n\t\t\t\t<input name='input_222' type='radio' value='Yes'  id='choice_6_222_0'    \/>\n\t\t\t\t<label for='choice_6_222_0' id='label_6_222_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_6_222_1'>\n\t\t\t\t<input name='input_222' type='radio' value='No'  id='choice_6_222_1'    \/>\n\t\t\t\t<label for='choice_6_222_1' id='label_6_222_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_223\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Heart 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_6_223'>\n\t\t\t<li class='gchoice gchoice_6_223_0'>\n\t\t\t\t<input name='input_223' type='radio' value='Yes'  id='choice_6_223_0'    \/>\n\t\t\t\t<label for='choice_6_223_0' id='label_6_223_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_6_223_1'>\n\t\t\t\t<input name='input_223' type='radio' value='No'  id='choice_6_223_1'    \/>\n\t\t\t\t<label for='choice_6_223_1' id='label_6_223_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_224\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Degenerative Disc 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_6_224'>\n\t\t\t<li class='gchoice gchoice_6_224_0'>\n\t\t\t\t<input name='input_224' type='radio' value='Yes'  id='choice_6_224_0'    \/>\n\t\t\t\t<label for='choice_6_224_0' id='label_6_224_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_6_224_1'>\n\t\t\t\t<input name='input_224' type='radio' value='No'  id='choice_6_224_1'    \/>\n\t\t\t\t<label for='choice_6_224_1' id='label_6_224_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_225'>\n\t\t\t<li class='gchoice gchoice_6_225_0'>\n\t\t\t\t<input name='input_225' type='radio' value='Yes'  id='choice_6_225_0'    \/>\n\t\t\t\t<label for='choice_6_225_0' id='label_6_225_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_6_225_1'>\n\t\t\t\t<input name='input_225' type='radio' value='No'  id='choice_6_225_1'    \/>\n\t\t\t\t<label for='choice_6_225_1' id='label_6_225_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_226\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Drug Abuse<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_6_226'>\n\t\t\t<li class='gchoice gchoice_6_226_0'>\n\t\t\t\t<input name='input_226' type='radio' value='Yes'  id='choice_6_226_0'    \/>\n\t\t\t\t<label for='choice_6_226_0' id='label_6_226_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_6_226_1'>\n\t\t\t\t<input name='input_226' type='radio' value='No'  id='choice_6_226_1'    \/>\n\t\t\t\t<label for='choice_6_226_1' id='label_6_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_227\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Social History<\/h2><\/li><li id=\"field_6_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_6_230'>\n\t\t\t<li class='gchoice gchoice_6_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='Yes'  id='choice_6_230_0'    \/>\n\t\t\t\t<label for='choice_6_230_0' id='label_6_230_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_6_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_6_230_1'    \/>\n\t\t\t\t<label for='choice_6_230_1' id='label_6_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_231\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_231'>How much?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_6_231' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_232\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 drink alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_232'>\n\t\t\t<li class='gchoice gchoice_6_232_0'>\n\t\t\t\t<input name='input_232' type='radio' value='Yes'  id='choice_6_232_0'    \/>\n\t\t\t\t<label for='choice_6_232_0' id='label_6_232_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_6_232_1'>\n\t\t\t\t<input name='input_232' type='radio' value='No'  id='choice_6_232_1'    \/>\n\t\t\t\t<label for='choice_6_232_1' id='label_6_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_233\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_233'>How much\/often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_6_233' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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 use recreational drugs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_234'>\n\t\t\t<li class='gchoice gchoice_6_234_0'>\n\t\t\t\t<input name='input_234' type='radio' value='Yes'  id='choice_6_234_0'    \/>\n\t\t\t\t<label for='choice_6_234_0' id='label_6_234_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_6_234_1'>\n\t\t\t\t<input name='input_234' type='radio' value='No'  id='choice_6_234_1'    \/>\n\t\t\t\t<label for='choice_6_234_1' id='label_6_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_235\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_235'>What kind of drugs?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_6_235' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_409\" class=\"gfield gfield--type-text gfield--input-type-text gf_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' for='input_6_409'>How much\/often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_409' id='input_6_409' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_236\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Activity Level<\/h2><\/li><li id=\"field_6_237\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_6_237'>Please describe your recreational activity level. What are your goals for treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_237' id='input_6_237' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_291' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_291' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_6' class='gform_page' data-js='page-field-id-291' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_292\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Symptoms<\/h2><div class='gsection_description' id='gfield_description_6_292'>The following is a record of any symptoms you may have had in the past or are ongoing. Please check the appropriate boxes for each.<\/div><\/li><li id=\"field_6_294\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">General<\/h2><\/li><li id=\"field_6_293\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Fatigue<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_6_293'>\n\t\t\t<li class='gchoice gchoice_6_293_0'>\n\t\t\t\t<input name='input_293' type='radio' value='Never'  id='choice_6_293_0'    \/>\n\t\t\t\t<label for='choice_6_293_0' id='label_6_293_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_293_1'>\n\t\t\t\t<input name='input_293' type='radio' value='Occasional'  id='choice_6_293_1'    \/>\n\t\t\t\t<label for='choice_6_293_1' id='label_6_293_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_293_2'>\n\t\t\t\t<input name='input_293' type='radio' value='Frequent'  id='choice_6_293_2'    \/>\n\t\t\t\t<label for='choice_6_293_2' id='label_6_293_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_295\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Irritable<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_6_295'>\n\t\t\t<li class='gchoice gchoice_6_295_0'>\n\t\t\t\t<input name='input_295' type='radio' value='Never'  id='choice_6_295_0'    \/>\n\t\t\t\t<label for='choice_6_295_0' id='label_6_295_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_295_1'>\n\t\t\t\t<input name='input_295' type='radio' value='Occasional'  id='choice_6_295_1'    \/>\n\t\t\t\t<label for='choice_6_295_1' id='label_6_295_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_295_2'>\n\t\t\t\t<input name='input_295' type='radio' value='Frequent'  id='choice_6_295_2'    \/>\n\t\t\t\t<label for='choice_6_295_2' id='label_6_295_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_296\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hot\/cold<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_6_296'>\n\t\t\t<li class='gchoice gchoice_6_296_0'>\n\t\t\t\t<input name='input_296' type='radio' value='Never'  id='choice_6_296_0'    \/>\n\t\t\t\t<label for='choice_6_296_0' id='label_6_296_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_296_1'>\n\t\t\t\t<input name='input_296' type='radio' value='Occasional'  id='choice_6_296_1'    \/>\n\t\t\t\t<label for='choice_6_296_1' id='label_6_296_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_296_2'>\n\t\t\t\t<input name='input_296' type='radio' value='Frequent'  id='choice_6_296_2'    \/>\n\t\t\t\t<label for='choice_6_296_2' id='label_6_296_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_297\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chills<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_6_297'>\n\t\t\t<li class='gchoice gchoice_6_297_0'>\n\t\t\t\t<input name='input_297' type='radio' value='Never'  id='choice_6_297_0'    \/>\n\t\t\t\t<label for='choice_6_297_0' id='label_6_297_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_297_1'>\n\t\t\t\t<input name='input_297' type='radio' value='Occasional'  id='choice_6_297_1'    \/>\n\t\t\t\t<label for='choice_6_297_1' id='label_6_297_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_297_2'>\n\t\t\t\t<input name='input_297' type='radio' value='Frequent'  id='choice_6_297_2'    \/>\n\t\t\t\t<label for='choice_6_297_2' id='label_6_297_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_298\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sweats<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_6_298'>\n\t\t\t<li class='gchoice gchoice_6_298_0'>\n\t\t\t\t<input name='input_298' type='radio' value='Never'  id='choice_6_298_0'    \/>\n\t\t\t\t<label for='choice_6_298_0' id='label_6_298_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_298_1'>\n\t\t\t\t<input name='input_298' type='radio' value='Occasional'  id='choice_6_298_1'    \/>\n\t\t\t\t<label for='choice_6_298_1' id='label_6_298_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_298_2'>\n\t\t\t\t<input name='input_298' type='radio' value='Frequent'  id='choice_6_298_2'    \/>\n\t\t\t\t<label for='choice_6_298_2' id='label_6_298_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_299\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tremors<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_6_299'>\n\t\t\t<li class='gchoice gchoice_6_299_0'>\n\t\t\t\t<input name='input_299' type='radio' value='Never'  id='choice_6_299_0'    \/>\n\t\t\t\t<label for='choice_6_299_0' id='label_6_299_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_299_1'>\n\t\t\t\t<input name='input_299' type='radio' value='Occasional'  id='choice_6_299_1'    \/>\n\t\t\t\t<label for='choice_6_299_1' id='label_6_299_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_299_2'>\n\t\t\t\t<input name='input_299' type='radio' value='Frequent'  id='choice_6_299_2'    \/>\n\t\t\t\t<label for='choice_6_299_2' id='label_6_299_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_300\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Weight gain<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_6_300'>\n\t\t\t<li class='gchoice gchoice_6_300_0'>\n\t\t\t\t<input name='input_300' type='radio' value='Never'  id='choice_6_300_0'    \/>\n\t\t\t\t<label for='choice_6_300_0' id='label_6_300_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_300_1'>\n\t\t\t\t<input name='input_300' type='radio' value='Occasional'  id='choice_6_300_1'    \/>\n\t\t\t\t<label for='choice_6_300_1' id='label_6_300_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_300_2'>\n\t\t\t\t<input name='input_300' type='radio' value='Frequent'  id='choice_6_300_2'    \/>\n\t\t\t\t<label for='choice_6_300_2' id='label_6_300_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_301\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Weight loss<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_6_301'>\n\t\t\t<li class='gchoice gchoice_6_301_0'>\n\t\t\t\t<input name='input_301' type='radio' value='Never'  id='choice_6_301_0'    \/>\n\t\t\t\t<label for='choice_6_301_0' id='label_6_301_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_301_1'>\n\t\t\t\t<input name='input_301' type='radio' value='Occasional'  id='choice_6_301_1'    \/>\n\t\t\t\t<label for='choice_6_301_1' id='label_6_301_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_301_2'>\n\t\t\t\t<input name='input_301' type='radio' value='Frequent'  id='choice_6_301_2'    \/>\n\t\t\t\t<label for='choice_6_301_2' id='label_6_301_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_302\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">HEAD\/NEUROLOGIC<\/h2><\/li><li id=\"field_6_303\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_303'>\n\t\t\t<li class='gchoice gchoice_6_303_0'>\n\t\t\t\t<input name='input_303' type='radio' value='Never'  id='choice_6_303_0'    \/>\n\t\t\t\t<label for='choice_6_303_0' id='label_6_303_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_303_1'>\n\t\t\t\t<input name='input_303' type='radio' value='Occasional'  id='choice_6_303_1'    \/>\n\t\t\t\t<label for='choice_6_303_1' id='label_6_303_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_303_2'>\n\t\t\t\t<input name='input_303' type='radio' value='Frequent'  id='choice_6_303_2'    \/>\n\t\t\t\t<label for='choice_6_303_2' id='label_6_303_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_304\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Head injury<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_6_304'>\n\t\t\t<li class='gchoice gchoice_6_304_0'>\n\t\t\t\t<input name='input_304' type='radio' value='Never'  id='choice_6_304_0'    \/>\n\t\t\t\t<label for='choice_6_304_0' id='label_6_304_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_304_1'>\n\t\t\t\t<input name='input_304' type='radio' value='Occasional'  id='choice_6_304_1'    \/>\n\t\t\t\t<label for='choice_6_304_1' id='label_6_304_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_304_2'>\n\t\t\t\t<input name='input_304' type='radio' value='Frequent'  id='choice_6_304_2'    \/>\n\t\t\t\t<label for='choice_6_304_2' id='label_6_304_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_305\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Neck injury<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_6_305'>\n\t\t\t<li class='gchoice gchoice_6_305_0'>\n\t\t\t\t<input name='input_305' type='radio' value='Never'  id='choice_6_305_0'    \/>\n\t\t\t\t<label for='choice_6_305_0' id='label_6_305_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_305_1'>\n\t\t\t\t<input name='input_305' type='radio' value='Occasional'  id='choice_6_305_1'    \/>\n\t\t\t\t<label for='choice_6_305_1' id='label_6_305_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_305_2'>\n\t\t\t\t<input name='input_305' type='radio' value='Frequent'  id='choice_6_305_2'    \/>\n\t\t\t\t<label for='choice_6_305_2' id='label_6_305_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_306\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dizziness<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_6_306'>\n\t\t\t<li class='gchoice gchoice_6_306_0'>\n\t\t\t\t<input name='input_306' type='radio' value='Never'  id='choice_6_306_0'    \/>\n\t\t\t\t<label for='choice_6_306_0' id='label_6_306_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_306_1'>\n\t\t\t\t<input name='input_306' type='radio' value='Occasional'  id='choice_6_306_1'    \/>\n\t\t\t\t<label for='choice_6_306_1' id='label_6_306_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_306_2'>\n\t\t\t\t<input name='input_306' type='radio' value='Frequent'  id='choice_6_306_2'    \/>\n\t\t\t\t<label for='choice_6_306_2' id='label_6_306_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_307\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Convulsions<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_6_307'>\n\t\t\t<li class='gchoice gchoice_6_307_0'>\n\t\t\t\t<input name='input_307' type='radio' value='Never'  id='choice_6_307_0'    \/>\n\t\t\t\t<label for='choice_6_307_0' id='label_6_307_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_307_1'>\n\t\t\t\t<input name='input_307' type='radio' value='Occasional'  id='choice_6_307_1'    \/>\n\t\t\t\t<label for='choice_6_307_1' id='label_6_307_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_307_2'>\n\t\t\t\t<input name='input_307' type='radio' value='Frequent'  id='choice_6_307_2'    \/>\n\t\t\t\t<label for='choice_6_307_2' id='label_6_307_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_308\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Slurred speech<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_6_308'>\n\t\t\t<li class='gchoice gchoice_6_308_0'>\n\t\t\t\t<input name='input_308' type='radio' value='Never'  id='choice_6_308_0'    \/>\n\t\t\t\t<label for='choice_6_308_0' id='label_6_308_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_308_1'>\n\t\t\t\t<input name='input_308' type='radio' value='Occasional'  id='choice_6_308_1'    \/>\n\t\t\t\t<label for='choice_6_308_1' id='label_6_308_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_308_2'>\n\t\t\t\t<input name='input_308' type='radio' value='Frequent'  id='choice_6_308_2'    \/>\n\t\t\t\t<label for='choice_6_308_2' id='label_6_308_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_309\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Memory loss<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_6_309'>\n\t\t\t<li class='gchoice gchoice_6_309_0'>\n\t\t\t\t<input name='input_309' type='radio' value='Never'  id='choice_6_309_0'    \/>\n\t\t\t\t<label for='choice_6_309_0' id='label_6_309_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_309_1'>\n\t\t\t\t<input name='input_309' type='radio' value='Occasional'  id='choice_6_309_1'    \/>\n\t\t\t\t<label for='choice_6_309_1' id='label_6_309_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_309_2'>\n\t\t\t\t<input name='input_309' type='radio' value='Frequent'  id='choice_6_309_2'    \/>\n\t\t\t\t<label for='choice_6_309_2' id='label_6_309_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_310\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Concentration 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_6_310'>\n\t\t\t<li class='gchoice gchoice_6_310_0'>\n\t\t\t\t<input name='input_310' type='radio' value='Never'  id='choice_6_310_0'    \/>\n\t\t\t\t<label for='choice_6_310_0' id='label_6_310_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_310_1'>\n\t\t\t\t<input name='input_310' type='radio' value='Occasional'  id='choice_6_310_1'    \/>\n\t\t\t\t<label for='choice_6_310_1' id='label_6_310_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_310_2'>\n\t\t\t\t<input name='input_310' type='radio' value='Frequent'  id='choice_6_310_2'    \/>\n\t\t\t\t<label for='choice_6_310_2' id='label_6_310_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_311\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Weakness<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_6_311'>\n\t\t\t<li class='gchoice gchoice_6_311_0'>\n\t\t\t\t<input name='input_311' type='radio' value='Never'  id='choice_6_311_0'    \/>\n\t\t\t\t<label for='choice_6_311_0' id='label_6_311_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_311_1'>\n\t\t\t\t<input name='input_311' type='radio' value='Occasional'  id='choice_6_311_1'    \/>\n\t\t\t\t<label for='choice_6_311_1' id='label_6_311_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_311_2'>\n\t\t\t\t<input name='input_311' type='radio' value='Frequent'  id='choice_6_311_2'    \/>\n\t\t\t\t<label for='choice_6_311_2' id='label_6_311_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_312\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Strokes<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_6_312'>\n\t\t\t<li class='gchoice gchoice_6_312_0'>\n\t\t\t\t<input name='input_312' type='radio' value='Never'  id='choice_6_312_0'    \/>\n\t\t\t\t<label for='choice_6_312_0' id='label_6_312_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_312_1'>\n\t\t\t\t<input name='input_312' type='radio' value='Occasional'  id='choice_6_312_1'    \/>\n\t\t\t\t<label for='choice_6_312_1' id='label_6_312_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_312_2'>\n\t\t\t\t<input name='input_312' type='radio' value='Frequent'  id='choice_6_312_2'    \/>\n\t\t\t\t<label for='choice_6_312_2' id='label_6_312_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_313\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Carpal tunnel<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_6_313'>\n\t\t\t<li class='gchoice gchoice_6_313_0'>\n\t\t\t\t<input name='input_313' type='radio' value='Never'  id='choice_6_313_0'    \/>\n\t\t\t\t<label for='choice_6_313_0' id='label_6_313_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_313_1'>\n\t\t\t\t<input name='input_313' type='radio' value='Occasional'  id='choice_6_313_1'    \/>\n\t\t\t\t<label for='choice_6_313_1' id='label_6_313_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_313_2'>\n\t\t\t\t<input name='input_313' type='radio' value='Frequent'  id='choice_6_313_2'    \/>\n\t\t\t\t<label for='choice_6_313_2' id='label_6_313_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_314\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">BONES\/JOINTS<\/h2><\/li><li id=\"field_6_315\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_315'>\n\t\t\t<li class='gchoice gchoice_6_315_0'>\n\t\t\t\t<input name='input_315' type='radio' value='Never'  id='choice_6_315_0'    \/>\n\t\t\t\t<label for='choice_6_315_0' id='label_6_315_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_315_1'>\n\t\t\t\t<input name='input_315' type='radio' value='Occasional'  id='choice_6_315_1'    \/>\n\t\t\t\t<label for='choice_6_315_1' id='label_6_315_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_315_2'>\n\t\t\t\t<input name='input_315' type='radio' value='Frequent'  id='choice_6_315_2'    \/>\n\t\t\t\t<label for='choice_6_315_2' id='label_6_315_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_316\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Bursitis<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_6_316'>\n\t\t\t<li class='gchoice gchoice_6_316_0'>\n\t\t\t\t<input name='input_316' type='radio' value='Never'  id='choice_6_316_0'    \/>\n\t\t\t\t<label for='choice_6_316_0' id='label_6_316_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_316_1'>\n\t\t\t\t<input name='input_316' type='radio' value='Occasional'  id='choice_6_316_1'    \/>\n\t\t\t\t<label for='choice_6_316_1' id='label_6_316_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_316_2'>\n\t\t\t\t<input name='input_316' type='radio' value='Frequent'  id='choice_6_316_2'    \/>\n\t\t\t\t<label for='choice_6_316_2' id='label_6_316_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_317\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tendonitis<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_6_317'>\n\t\t\t<li class='gchoice gchoice_6_317_0'>\n\t\t\t\t<input name='input_317' type='radio' value='Never'  id='choice_6_317_0'    \/>\n\t\t\t\t<label for='choice_6_317_0' id='label_6_317_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_317_1'>\n\t\t\t\t<input name='input_317' type='radio' value='Occasional'  id='choice_6_317_1'    \/>\n\t\t\t\t<label for='choice_6_317_1' id='label_6_317_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_317_2'>\n\t\t\t\t<input name='input_317' type='radio' value='Frequent'  id='choice_6_317_2'    \/>\n\t\t\t\t<label for='choice_6_317_2' id='label_6_317_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_318\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Cramps\/spasms<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_6_318'>\n\t\t\t<li class='gchoice gchoice_6_318_0'>\n\t\t\t\t<input name='input_318' type='radio' value='Never'  id='choice_6_318_0'    \/>\n\t\t\t\t<label for='choice_6_318_0' id='label_6_318_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_318_1'>\n\t\t\t\t<input name='input_318' type='radio' value='Occasional'  id='choice_6_318_1'    \/>\n\t\t\t\t<label for='choice_6_318_1' id='label_6_318_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_318_2'>\n\t\t\t\t<input name='input_318' type='radio' value='Frequent'  id='choice_6_318_2'    \/>\n\t\t\t\t<label for='choice_6_318_2' id='label_6_318_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_319\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Swollen joints<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_6_319'>\n\t\t\t<li class='gchoice gchoice_6_319_0'>\n\t\t\t\t<input name='input_319' type='radio' value='Never'  id='choice_6_319_0'    \/>\n\t\t\t\t<label for='choice_6_319_0' id='label_6_319_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_319_1'>\n\t\t\t\t<input name='input_319' type='radio' value='Occasional'  id='choice_6_319_1'    \/>\n\t\t\t\t<label for='choice_6_319_1' id='label_6_319_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_319_2'>\n\t\t\t\t<input name='input_319' type='radio' value='Frequent'  id='choice_6_319_2'    \/>\n\t\t\t\t<label for='choice_6_319_2' id='label_6_319_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_320\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pain between shoulders<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_6_320'>\n\t\t\t<li class='gchoice gchoice_6_320_0'>\n\t\t\t\t<input name='input_320' type='radio' value='Never'  id='choice_6_320_0'    \/>\n\t\t\t\t<label for='choice_6_320_0' id='label_6_320_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_320_1'>\n\t\t\t\t<input name='input_320' type='radio' value='Occasional'  id='choice_6_320_1'    \/>\n\t\t\t\t<label for='choice_6_320_1' id='label_6_320_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_320_2'>\n\t\t\t\t<input name='input_320' type='radio' value='Frequent'  id='choice_6_320_2'    \/>\n\t\t\t\t<label for='choice_6_320_2' id='label_6_320_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_321\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Back pain<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_6_321'>\n\t\t\t<li class='gchoice gchoice_6_321_0'>\n\t\t\t\t<input name='input_321' type='radio' value='Never'  id='choice_6_321_0'    \/>\n\t\t\t\t<label for='choice_6_321_0' id='label_6_321_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_321_1'>\n\t\t\t\t<input name='input_321' type='radio' value='Occasional'  id='choice_6_321_1'    \/>\n\t\t\t\t<label for='choice_6_321_1' id='label_6_321_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_321_2'>\n\t\t\t\t<input name='input_321' type='radio' value='Frequent'  id='choice_6_321_2'    \/>\n\t\t\t\t<label for='choice_6_321_2' id='label_6_321_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_322\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chiropractic 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_6_322'>\n\t\t\t<li class='gchoice gchoice_6_322_0'>\n\t\t\t\t<input name='input_322' type='radio' value='Never'  id='choice_6_322_0'    \/>\n\t\t\t\t<label for='choice_6_322_0' id='label_6_322_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_322_1'>\n\t\t\t\t<input name='input_322' type='radio' value='Occasional'  id='choice_6_322_1'    \/>\n\t\t\t\t<label for='choice_6_322_1' id='label_6_322_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_322_2'>\n\t\t\t\t<input name='input_322' type='radio' value='Frequent'  id='choice_6_322_2'    \/>\n\t\t\t\t<label for='choice_6_322_2' id='label_6_322_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_323\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dislocations<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_6_323'>\n\t\t\t<li class='gchoice gchoice_6_323_0'>\n\t\t\t\t<input name='input_323' type='radio' value='Never'  id='choice_6_323_0'    \/>\n\t\t\t\t<label for='choice_6_323_0' id='label_6_323_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_323_1'>\n\t\t\t\t<input name='input_323' type='radio' value='Occasional'  id='choice_6_323_1'    \/>\n\t\t\t\t<label for='choice_6_323_1' id='label_6_323_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_323_2'>\n\t\t\t\t<input name='input_323' type='radio' value='Frequent'  id='choice_6_323_2'    \/>\n\t\t\t\t<label for='choice_6_323_2' id='label_6_323_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_324\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Gout<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_6_324'>\n\t\t\t<li class='gchoice gchoice_6_324_0'>\n\t\t\t\t<input name='input_324' type='radio' value='Never'  id='choice_6_324_0'    \/>\n\t\t\t\t<label for='choice_6_324_0' id='label_6_324_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_324_1'>\n\t\t\t\t<input name='input_324' type='radio' value='Occasional'  id='choice_6_324_1'    \/>\n\t\t\t\t<label for='choice_6_324_1' id='label_6_324_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_324_2'>\n\t\t\t\t<input name='input_324' type='radio' value='Frequent'  id='choice_6_324_2'    \/>\n\t\t\t\t<label for='choice_6_324_2' id='label_6_324_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_325\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Stiffness<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_6_325'>\n\t\t\t<li class='gchoice gchoice_6_325_0'>\n\t\t\t\t<input name='input_325' type='radio' value='Never'  id='choice_6_325_0'    \/>\n\t\t\t\t<label for='choice_6_325_0' id='label_6_325_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_325_1'>\n\t\t\t\t<input name='input_325' type='radio' value='Occasional'  id='choice_6_325_1'    \/>\n\t\t\t\t<label for='choice_6_325_1' id='label_6_325_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_325_2'>\n\t\t\t\t<input name='input_325' type='radio' value='Frequent'  id='choice_6_325_2'    \/>\n\t\t\t\t<label for='choice_6_325_2' id='label_6_325_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_326\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Osteoporosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_326'>\n\t\t\t<li class='gchoice gchoice_6_326_0'>\n\t\t\t\t<input name='input_326' type='radio' value='Never'  id='choice_6_326_0'    \/>\n\t\t\t\t<label for='choice_6_326_0' id='label_6_326_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_326_1'>\n\t\t\t\t<input name='input_326' type='radio' value='Occasional'  id='choice_6_326_1'    \/>\n\t\t\t\t<label for='choice_6_326_1' id='label_6_326_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_326_2'>\n\t\t\t\t<input name='input_326' type='radio' value='Frequent'  id='choice_6_326_2'    \/>\n\t\t\t\t<label for='choice_6_326_2' id='label_6_326_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_328\" class=\"gfield gfield--type-html gfield--input-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\"  ><span style=\"font-weight: bold; \n    font-size: 100%; color: #666666; text-decoration: underline !important;\" >Pain or numbness in...<\/span><\/li><li id=\"field_6_327\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... shoulders<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_6_327'>\n\t\t\t<li class='gchoice gchoice_6_327_0'>\n\t\t\t\t<input name='input_327' type='radio' value='Never'  id='choice_6_327_0'    \/>\n\t\t\t\t<label for='choice_6_327_0' id='label_6_327_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_327_1'>\n\t\t\t\t<input name='input_327' type='radio' value='Occasional'  id='choice_6_327_1'    \/>\n\t\t\t\t<label for='choice_6_327_1' id='label_6_327_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_327_2'>\n\t\t\t\t<input name='input_327' type='radio' value='Frequent'  id='choice_6_327_2'    \/>\n\t\t\t\t<label for='choice_6_327_2' id='label_6_327_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_329\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... arms<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_6_329'>\n\t\t\t<li class='gchoice gchoice_6_329_0'>\n\t\t\t\t<input name='input_329' type='radio' value='Never'  id='choice_6_329_0'    \/>\n\t\t\t\t<label for='choice_6_329_0' id='label_6_329_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_329_1'>\n\t\t\t\t<input name='input_329' type='radio' value='Occasional'  id='choice_6_329_1'    \/>\n\t\t\t\t<label for='choice_6_329_1' id='label_6_329_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_329_2'>\n\t\t\t\t<input name='input_329' type='radio' value='Frequent'  id='choice_6_329_2'    \/>\n\t\t\t\t<label for='choice_6_329_2' id='label_6_329_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_330\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... elbows<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_6_330'>\n\t\t\t<li class='gchoice gchoice_6_330_0'>\n\t\t\t\t<input name='input_330' type='radio' value='Never'  id='choice_6_330_0'    \/>\n\t\t\t\t<label for='choice_6_330_0' id='label_6_330_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_330_1'>\n\t\t\t\t<input name='input_330' type='radio' value='Occasional'  id='choice_6_330_1'    \/>\n\t\t\t\t<label for='choice_6_330_1' id='label_6_330_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_330_2'>\n\t\t\t\t<input name='input_330' type='radio' value='Frequent'  id='choice_6_330_2'    \/>\n\t\t\t\t<label for='choice_6_330_2' id='label_6_330_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_331\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... wrists<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_6_331'>\n\t\t\t<li class='gchoice gchoice_6_331_0'>\n\t\t\t\t<input name='input_331' type='radio' value='Never'  id='choice_6_331_0'    \/>\n\t\t\t\t<label for='choice_6_331_0' id='label_6_331_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_331_1'>\n\t\t\t\t<input name='input_331' type='radio' value='Occasional'  id='choice_6_331_1'    \/>\n\t\t\t\t<label for='choice_6_331_1' id='label_6_331_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_331_2'>\n\t\t\t\t<input name='input_331' type='radio' value='Frequent'  id='choice_6_331_2'    \/>\n\t\t\t\t<label for='choice_6_331_2' id='label_6_331_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_332\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... hands<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_6_332'>\n\t\t\t<li class='gchoice gchoice_6_332_0'>\n\t\t\t\t<input name='input_332' type='radio' value='Never'  id='choice_6_332_0'    \/>\n\t\t\t\t<label for='choice_6_332_0' id='label_6_332_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_332_1'>\n\t\t\t\t<input name='input_332' type='radio' value='Occasional'  id='choice_6_332_1'    \/>\n\t\t\t\t<label for='choice_6_332_1' id='label_6_332_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_332_2'>\n\t\t\t\t<input name='input_332' type='radio' value='Frequent'  id='choice_6_332_2'    \/>\n\t\t\t\t<label for='choice_6_332_2' id='label_6_332_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_333\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... hips<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_6_333'>\n\t\t\t<li class='gchoice gchoice_6_333_0'>\n\t\t\t\t<input name='input_333' type='radio' value='Never'  id='choice_6_333_0'    \/>\n\t\t\t\t<label for='choice_6_333_0' id='label_6_333_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_333_1'>\n\t\t\t\t<input name='input_333' type='radio' value='Occasional'  id='choice_6_333_1'    \/>\n\t\t\t\t<label for='choice_6_333_1' id='label_6_333_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_333_2'>\n\t\t\t\t<input name='input_333' type='radio' value='Frequent'  id='choice_6_333_2'    \/>\n\t\t\t\t<label for='choice_6_333_2' id='label_6_333_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_334\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... legs<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_6_334'>\n\t\t\t<li class='gchoice gchoice_6_334_0'>\n\t\t\t\t<input name='input_334' type='radio' value='Never'  id='choice_6_334_0'    \/>\n\t\t\t\t<label for='choice_6_334_0' id='label_6_334_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_334_1'>\n\t\t\t\t<input name='input_334' type='radio' value='Occasional'  id='choice_6_334_1'    \/>\n\t\t\t\t<label for='choice_6_334_1' id='label_6_334_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_334_2'>\n\t\t\t\t<input name='input_334' type='radio' value='Frequent'  id='choice_6_334_2'    \/>\n\t\t\t\t<label for='choice_6_334_2' id='label_6_334_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_335\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >... knees<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_6_335'>\n\t\t\t<li class='gchoice gchoice_6_335_0'>\n\t\t\t\t<input name='input_335' type='radio' value='Never'  id='choice_6_335_0'    \/>\n\t\t\t\t<label for='choice_6_335_0' id='label_6_335_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_335_1'>\n\t\t\t\t<input name='input_335' type='radio' value='Occasional'  id='choice_6_335_1'    \/>\n\t\t\t\t<label for='choice_6_335_1' id='label_6_335_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_335_2'>\n\t\t\t\t<input name='input_335' type='radio' value='Frequent'  id='choice_6_335_2'    \/>\n\t\t\t\t<label for='choice_6_335_2' id='label_6_335_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_336\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >... feet<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_6_336'>\n\t\t\t<li class='gchoice gchoice_6_336_0'>\n\t\t\t\t<input name='input_336' type='radio' value='Never'  id='choice_6_336_0'    \/>\n\t\t\t\t<label for='choice_6_336_0' id='label_6_336_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_336_1'>\n\t\t\t\t<input name='input_336' type='radio' value='Occasional'  id='choice_6_336_1'    \/>\n\t\t\t\t<label for='choice_6_336_1' id='label_6_336_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_336_2'>\n\t\t\t\t<input name='input_336' type='radio' value='Frequent'  id='choice_6_336_2'    \/>\n\t\t\t\t<label for='choice_6_336_2' id='label_6_336_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_337\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Painful tailbone<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_6_337'>\n\t\t\t<li class='gchoice gchoice_6_337_0'>\n\t\t\t\t<input name='input_337' type='radio' value='Never'  id='choice_6_337_0'    \/>\n\t\t\t\t<label for='choice_6_337_0' id='label_6_337_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_337_1'>\n\t\t\t\t<input name='input_337' type='radio' value='Occasional'  id='choice_6_337_1'    \/>\n\t\t\t\t<label for='choice_6_337_1' id='label_6_337_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_337_2'>\n\t\t\t\t<input name='input_337' type='radio' value='Frequent'  id='choice_6_337_2'    \/>\n\t\t\t\t<label for='choice_6_337_2' id='label_6_337_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_338\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Poor posture<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_6_338'>\n\t\t\t<li class='gchoice gchoice_6_338_0'>\n\t\t\t\t<input name='input_338' type='radio' value='Never'  id='choice_6_338_0'    \/>\n\t\t\t\t<label for='choice_6_338_0' id='label_6_338_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_338_1'>\n\t\t\t\t<input name='input_338' type='radio' value='Occasional'  id='choice_6_338_1'    \/>\n\t\t\t\t<label for='choice_6_338_1' id='label_6_338_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_338_2'>\n\t\t\t\t<input name='input_338' type='radio' value='Frequent'  id='choice_6_338_2'    \/>\n\t\t\t\t<label for='choice_6_338_2' id='label_6_338_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_339\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sciatica<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_6_339'>\n\t\t\t<li class='gchoice gchoice_6_339_0'>\n\t\t\t\t<input name='input_339' type='radio' value='Never'  id='choice_6_339_0'    \/>\n\t\t\t\t<label for='choice_6_339_0' id='label_6_339_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_339_1'>\n\t\t\t\t<input name='input_339' type='radio' value='Occasional'  id='choice_6_339_1'    \/>\n\t\t\t\t<label for='choice_6_339_1' id='label_6_339_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_339_2'>\n\t\t\t\t<input name='input_339' type='radio' value='Frequent'  id='choice_6_339_2'    \/>\n\t\t\t\t<label for='choice_6_339_2' id='label_6_339_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_340\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Spinal curvature<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_6_340'>\n\t\t\t<li class='gchoice gchoice_6_340_0'>\n\t\t\t\t<input name='input_340' type='radio' value='Never'  id='choice_6_340_0'    \/>\n\t\t\t\t<label for='choice_6_340_0' id='label_6_340_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_340_1'>\n\t\t\t\t<input name='input_340' type='radio' value='Occasional'  id='choice_6_340_1'    \/>\n\t\t\t\t<label for='choice_6_340_1' id='label_6_340_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_340_2'>\n\t\t\t\t<input name='input_340' type='radio' value='Frequent'  id='choice_6_340_2'    \/>\n\t\t\t\t<label for='choice_6_340_2' id='label_6_340_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_341\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">KIDNEYS\/BLADDER<\/h2><\/li><li id=\"field_6_342\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood in urine<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_6_342'>\n\t\t\t<li class='gchoice gchoice_6_342_0'>\n\t\t\t\t<input name='input_342' type='radio' value='Never'  id='choice_6_342_0'    \/>\n\t\t\t\t<label for='choice_6_342_0' id='label_6_342_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_342_1'>\n\t\t\t\t<input name='input_342' type='radio' value='Occasional'  id='choice_6_342_1'    \/>\n\t\t\t\t<label for='choice_6_342_1' id='label_6_342_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_342_2'>\n\t\t\t\t<input name='input_342' type='radio' value='Frequent'  id='choice_6_342_2'    \/>\n\t\t\t\t<label for='choice_6_342_2' id='label_6_342_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_343\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent urination<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_6_343'>\n\t\t\t<li class='gchoice gchoice_6_343_0'>\n\t\t\t\t<input name='input_343' type='radio' value='Never'  id='choice_6_343_0'    \/>\n\t\t\t\t<label for='choice_6_343_0' id='label_6_343_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_343_1'>\n\t\t\t\t<input name='input_343' type='radio' value='Occasional'  id='choice_6_343_1'    \/>\n\t\t\t\t<label for='choice_6_343_1' id='label_6_343_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_343_2'>\n\t\t\t\t<input name='input_343' type='radio' value='Frequent'  id='choice_6_343_2'    \/>\n\t\t\t\t<label for='choice_6_343_2' id='label_6_343_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_344\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Painful urination<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_6_344'>\n\t\t\t<li class='gchoice gchoice_6_344_0'>\n\t\t\t\t<input name='input_344' type='radio' value='Never'  id='choice_6_344_0'    \/>\n\t\t\t\t<label for='choice_6_344_0' id='label_6_344_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_344_1'>\n\t\t\t\t<input name='input_344' type='radio' value='Occasional'  id='choice_6_344_1'    \/>\n\t\t\t\t<label for='choice_6_344_1' id='label_6_344_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_344_2'>\n\t\t\t\t<input name='input_344' type='radio' value='Frequent'  id='choice_6_344_2'    \/>\n\t\t\t\t<label for='choice_6_344_2' id='label_6_344_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_345\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Kidney stones<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_6_345'>\n\t\t\t<li class='gchoice gchoice_6_345_0'>\n\t\t\t\t<input name='input_345' type='radio' value='Never'  id='choice_6_345_0'    \/>\n\t\t\t\t<label for='choice_6_345_0' id='label_6_345_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_345_1'>\n\t\t\t\t<input name='input_345' type='radio' value='Occasional'  id='choice_6_345_1'    \/>\n\t\t\t\t<label for='choice_6_345_1' id='label_6_345_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_345_2'>\n\t\t\t\t<input name='input_345' type='radio' value='Frequent'  id='choice_6_345_2'    \/>\n\t\t\t\t<label for='choice_6_345_2' id='label_6_345_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_346\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Urinary infections<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_6_346'>\n\t\t\t<li class='gchoice gchoice_6_346_0'>\n\t\t\t\t<input name='input_346' type='radio' value='Never'  id='choice_6_346_0'    \/>\n\t\t\t\t<label for='choice_6_346_0' id='label_6_346_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_346_1'>\n\t\t\t\t<input name='input_346' type='radio' value='Occasional'  id='choice_6_346_1'    \/>\n\t\t\t\t<label for='choice_6_346_1' id='label_6_346_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_346_2'>\n\t\t\t\t<input name='input_346' type='radio' value='Frequent'  id='choice_6_346_2'    \/>\n\t\t\t\t<label for='choice_6_346_2' id='label_6_346_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_347\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Incontinence<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_6_347'>\n\t\t\t<li class='gchoice gchoice_6_347_0'>\n\t\t\t\t<input name='input_347' type='radio' value='Never'  id='choice_6_347_0'    \/>\n\t\t\t\t<label for='choice_6_347_0' id='label_6_347_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_347_1'>\n\t\t\t\t<input name='input_347' type='radio' value='Occasional'  id='choice_6_347_1'    \/>\n\t\t\t\t<label for='choice_6_347_1' id='label_6_347_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_347_2'>\n\t\t\t\t<input name='input_347' type='radio' value='Frequent'  id='choice_6_347_2'    \/>\n\t\t\t\t<label for='choice_6_347_2' id='label_6_347_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_348\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">EYES<\/h2><\/li><li id=\"field_6_349\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blurry vision<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_6_349'>\n\t\t\t<li class='gchoice gchoice_6_349_0'>\n\t\t\t\t<input name='input_349' type='radio' value='Never'  id='choice_6_349_0'    \/>\n\t\t\t\t<label for='choice_6_349_0' id='label_6_349_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_349_1'>\n\t\t\t\t<input name='input_349' type='radio' value='Occasional'  id='choice_6_349_1'    \/>\n\t\t\t\t<label for='choice_6_349_1' id='label_6_349_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_349_2'>\n\t\t\t\t<input name='input_349' type='radio' value='Frequent'  id='choice_6_349_2'    \/>\n\t\t\t\t<label for='choice_6_349_2' id='label_6_349_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_350\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Double vision<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_6_350'>\n\t\t\t<li class='gchoice gchoice_6_350_0'>\n\t\t\t\t<input name='input_350' type='radio' value='Never'  id='choice_6_350_0'    \/>\n\t\t\t\t<label for='choice_6_350_0' id='label_6_350_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_350_1'>\n\t\t\t\t<input name='input_350' type='radio' value='Occasional'  id='choice_6_350_1'    \/>\n\t\t\t\t<label for='choice_6_350_1' id='label_6_350_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_350_2'>\n\t\t\t\t<input name='input_350' type='radio' value='Frequent'  id='choice_6_350_2'    \/>\n\t\t\t\t<label for='choice_6_350_2' id='label_6_350_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_351\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Eye pain<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_6_351'>\n\t\t\t<li class='gchoice gchoice_6_351_0'>\n\t\t\t\t<input name='input_351' type='radio' value='Never'  id='choice_6_351_0'    \/>\n\t\t\t\t<label for='choice_6_351_0' id='label_6_351_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_351_1'>\n\t\t\t\t<input name='input_351' type='radio' value='Occasional'  id='choice_6_351_1'    \/>\n\t\t\t\t<label for='choice_6_351_1' id='label_6_351_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_351_2'>\n\t\t\t\t<input name='input_351' type='radio' value='Frequent'  id='choice_6_351_2'    \/>\n\t\t\t\t<label for='choice_6_351_2' id='label_6_351_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_352\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">EARS<\/h2><\/li><li id=\"field_6_353\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ringing\/buzzing<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_6_353'>\n\t\t\t<li class='gchoice gchoice_6_353_0'>\n\t\t\t\t<input name='input_353' type='radio' value='Never'  id='choice_6_353_0'    \/>\n\t\t\t\t<label for='choice_6_353_0' id='label_6_353_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_353_1'>\n\t\t\t\t<input name='input_353' type='radio' value='Occasional'  id='choice_6_353_1'    \/>\n\t\t\t\t<label for='choice_6_353_1' id='label_6_353_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_353_2'>\n\t\t\t\t<input name='input_353' type='radio' value='Frequent'  id='choice_6_353_2'    \/>\n\t\t\t\t<label for='choice_6_353_2' id='label_6_353_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_354\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Drainage<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_6_354'>\n\t\t\t<li class='gchoice gchoice_6_354_0'>\n\t\t\t\t<input name='input_354' type='radio' value='Never'  id='choice_6_354_0'    \/>\n\t\t\t\t<label for='choice_6_354_0' id='label_6_354_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_354_1'>\n\t\t\t\t<input name='input_354' type='radio' value='Occasional'  id='choice_6_354_1'    \/>\n\t\t\t\t<label for='choice_6_354_1' id='label_6_354_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_354_2'>\n\t\t\t\t<input name='input_354' type='radio' value='Frequent'  id='choice_6_354_2'    \/>\n\t\t\t\t<label for='choice_6_354_2' id='label_6_354_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_355\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Motion sickness<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_6_355'>\n\t\t\t<li class='gchoice gchoice_6_355_0'>\n\t\t\t\t<input name='input_355' type='radio' value='Never'  id='choice_6_355_0'    \/>\n\t\t\t\t<label for='choice_6_355_0' id='label_6_355_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_355_1'>\n\t\t\t\t<input name='input_355' type='radio' value='Occasional'  id='choice_6_355_1'    \/>\n\t\t\t\t<label for='choice_6_355_1' id='label_6_355_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_355_2'>\n\t\t\t\t<input name='input_355' type='radio' value='Frequent'  id='choice_6_355_2'    \/>\n\t\t\t\t<label for='choice_6_355_2' id='label_6_355_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_356\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Loss of hearing<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_6_356'>\n\t\t\t<li class='gchoice gchoice_6_356_0'>\n\t\t\t\t<input name='input_356' type='radio' value='Never'  id='choice_6_356_0'    \/>\n\t\t\t\t<label for='choice_6_356_0' id='label_6_356_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_356_1'>\n\t\t\t\t<input name='input_356' type='radio' value='Occasional'  id='choice_6_356_1'    \/>\n\t\t\t\t<label for='choice_6_356_1' id='label_6_356_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_356_2'>\n\t\t\t\t<input name='input_356' type='radio' value='Frequent'  id='choice_6_356_2'    \/>\n\t\t\t\t<label for='choice_6_356_2' id='label_6_356_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_357\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">FACE\/THROAT<\/h2><\/li><li id=\"field_6_358\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_358'>\n\t\t\t<li class='gchoice gchoice_6_358_0'>\n\t\t\t\t<input name='input_358' type='radio' value='Never'  id='choice_6_358_0'    \/>\n\t\t\t\t<label for='choice_6_358_0' id='label_6_358_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_358_1'>\n\t\t\t\t<input name='input_358' type='radio' value='Occasional'  id='choice_6_358_1'    \/>\n\t\t\t\t<label for='choice_6_358_1' id='label_6_358_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_358_2'>\n\t\t\t\t<input name='input_358' type='radio' value='Frequent'  id='choice_6_358_2'    \/>\n\t\t\t\t<label for='choice_6_358_2' id='label_6_358_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_359\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Frequent colds<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_6_359'>\n\t\t\t<li class='gchoice gchoice_6_359_0'>\n\t\t\t\t<input name='input_359' type='radio' value='Never'  id='choice_6_359_0'    \/>\n\t\t\t\t<label for='choice_6_359_0' id='label_6_359_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_359_1'>\n\t\t\t\t<input name='input_359' type='radio' value='Occasional'  id='choice_6_359_1'    \/>\n\t\t\t\t<label for='choice_6_359_1' id='label_6_359_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_359_2'>\n\t\t\t\t<input name='input_359' type='radio' value='Frequent'  id='choice_6_359_2'    \/>\n\t\t\t\t<label for='choice_6_359_2' id='label_6_359_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_360\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Problems swallowing<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_6_360'>\n\t\t\t<li class='gchoice gchoice_6_360_0'>\n\t\t\t\t<input name='input_360' type='radio' value='Never'  id='choice_6_360_0'    \/>\n\t\t\t\t<label for='choice_6_360_0' id='label_6_360_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_360_1'>\n\t\t\t\t<input name='input_360' type='radio' value='Occasional'  id='choice_6_360_1'    \/>\n\t\t\t\t<label for='choice_6_360_1' id='label_6_360_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_360_2'>\n\t\t\t\t<input name='input_360' type='radio' value='Frequent'  id='choice_6_360_2'    \/>\n\t\t\t\t<label for='choice_6_360_2' id='label_6_360_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_361\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pain in chewing<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_6_361'>\n\t\t\t<li class='gchoice gchoice_6_361_0'>\n\t\t\t\t<input name='input_361' type='radio' value='Never'  id='choice_6_361_0'    \/>\n\t\t\t\t<label for='choice_6_361_0' id='label_6_361_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_361_1'>\n\t\t\t\t<input name='input_361' type='radio' value='Occasional'  id='choice_6_361_1'    \/>\n\t\t\t\t<label for='choice_6_361_1' id='label_6_361_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_361_2'>\n\t\t\t\t<input name='input_361' type='radio' value='Frequent'  id='choice_6_361_2'    \/>\n\t\t\t\t<label for='choice_6_361_2' id='label_6_361_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_362\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pain in your jaw(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_362'>\n\t\t\t<li class='gchoice gchoice_6_362_0'>\n\t\t\t\t<input name='input_362' type='radio' value='Never'  id='choice_6_362_0'    \/>\n\t\t\t\t<label for='choice_6_362_0' id='label_6_362_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_362_1'>\n\t\t\t\t<input name='input_362' type='radio' value='Occasional'  id='choice_6_362_1'    \/>\n\t\t\t\t<label for='choice_6_362_1' id='label_6_362_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_362_2'>\n\t\t\t\t<input name='input_362' type='radio' value='Frequent'  id='choice_6_362_2'    \/>\n\t\t\t\t<label for='choice_6_362_2' id='label_6_362_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_363\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dentures<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_6_363'>\n\t\t\t<li class='gchoice gchoice_6_363_0'>\n\t\t\t\t<input name='input_363' type='radio' value='Never'  id='choice_6_363_0'    \/>\n\t\t\t\t<label for='choice_6_363_0' id='label_6_363_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_363_1'>\n\t\t\t\t<input name='input_363' type='radio' value='Occasional'  id='choice_6_363_1'    \/>\n\t\t\t\t<label for='choice_6_363_1' id='label_6_363_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_363_2'>\n\t\t\t\t<input name='input_363' type='radio' value='Frequent'  id='choice_6_363_2'    \/>\n\t\t\t\t<label for='choice_6_363_2' id='label_6_363_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_365\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">LUNGS<\/h2><\/li><li id=\"field_6_364\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Tuberculosis<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_6_364'>\n\t\t\t<li class='gchoice gchoice_6_364_0'>\n\t\t\t\t<input name='input_364' type='radio' value='Never'  id='choice_6_364_0'    \/>\n\t\t\t\t<label for='choice_6_364_0' id='label_6_364_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_364_1'>\n\t\t\t\t<input name='input_364' type='radio' value='Occasional'  id='choice_6_364_1'    \/>\n\t\t\t\t<label for='choice_6_364_1' id='label_6_364_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_364_2'>\n\t\t\t\t<input name='input_364' type='radio' value='Frequent'  id='choice_6_364_2'    \/>\n\t\t\t\t<label for='choice_6_364_2' id='label_6_364_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_366\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_366'>\n\t\t\t<li class='gchoice gchoice_6_366_0'>\n\t\t\t\t<input name='input_366' type='radio' value='Never'  id='choice_6_366_0'    \/>\n\t\t\t\t<label for='choice_6_366_0' id='label_6_366_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_366_1'>\n\t\t\t\t<input name='input_366' type='radio' value='Occasional'  id='choice_6_366_1'    \/>\n\t\t\t\t<label for='choice_6_366_1' id='label_6_366_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_366_2'>\n\t\t\t\t<input name='input_366' type='radio' value='Frequent'  id='choice_6_366_2'    \/>\n\t\t\t\t<label for='choice_6_366_2' id='label_6_366_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_367\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pneumonia<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_6_367'>\n\t\t\t<li class='gchoice gchoice_6_367_0'>\n\t\t\t\t<input name='input_367' type='radio' value='Never'  id='choice_6_367_0'    \/>\n\t\t\t\t<label for='choice_6_367_0' id='label_6_367_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_367_1'>\n\t\t\t\t<input name='input_367' type='radio' value='Occasional'  id='choice_6_367_1'    \/>\n\t\t\t\t<label for='choice_6_367_1' id='label_6_367_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_367_2'>\n\t\t\t\t<input name='input_367' type='radio' value='Frequent'  id='choice_6_367_2'    \/>\n\t\t\t\t<label for='choice_6_367_2' id='label_6_367_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_368\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Shortness of breath<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_6_368'>\n\t\t\t<li class='gchoice gchoice_6_368_0'>\n\t\t\t\t<input name='input_368' type='radio' value='Never'  id='choice_6_368_0'    \/>\n\t\t\t\t<label for='choice_6_368_0' id='label_6_368_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_368_1'>\n\t\t\t\t<input name='input_368' type='radio' value='Occasional'  id='choice_6_368_1'    \/>\n\t\t\t\t<label for='choice_6_368_1' id='label_6_368_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_368_2'>\n\t\t\t\t<input name='input_368' type='radio' value='Frequent'  id='choice_6_368_2'    \/>\n\t\t\t\t<label for='choice_6_368_2' id='label_6_368_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_369\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chronic 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_6_369'>\n\t\t\t<li class='gchoice gchoice_6_369_0'>\n\t\t\t\t<input name='input_369' type='radio' value='Never'  id='choice_6_369_0'    \/>\n\t\t\t\t<label for='choice_6_369_0' id='label_6_369_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_369_1'>\n\t\t\t\t<input name='input_369' type='radio' value='Occasional'  id='choice_6_369_1'    \/>\n\t\t\t\t<label for='choice_6_369_1' id='label_6_369_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_369_2'>\n\t\t\t\t<input name='input_369' type='radio' value='Frequent'  id='choice_6_369_2'    \/>\n\t\t\t\t<label for='choice_6_369_2' id='label_6_369_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_370\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Wheezing<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_6_370'>\n\t\t\t<li class='gchoice gchoice_6_370_0'>\n\t\t\t\t<input name='input_370' type='radio' value='Never'  id='choice_6_370_0'    \/>\n\t\t\t\t<label for='choice_6_370_0' id='label_6_370_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_370_1'>\n\t\t\t\t<input name='input_370' type='radio' value='Occasional'  id='choice_6_370_1'    \/>\n\t\t\t\t<label for='choice_6_370_1' id='label_6_370_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_370_2'>\n\t\t\t\t<input name='input_370' type='radio' value='Frequent'  id='choice_6_370_2'    \/>\n\t\t\t\t<label for='choice_6_370_2' id='label_6_370_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_371\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood clots<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_6_371'>\n\t\t\t<li class='gchoice gchoice_6_371_0'>\n\t\t\t\t<input name='input_371' type='radio' value='Never'  id='choice_6_371_0'    \/>\n\t\t\t\t<label for='choice_6_371_0' id='label_6_371_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_371_1'>\n\t\t\t\t<input name='input_371' type='radio' value='Occasional'  id='choice_6_371_1'    \/>\n\t\t\t\t<label for='choice_6_371_1' id='label_6_371_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_371_2'>\n\t\t\t\t<input name='input_371' type='radio' value='Frequent'  id='choice_6_371_2'    \/>\n\t\t\t\t<label for='choice_6_371_2' id='label_6_371_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_373\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">HEART<\/h2><\/li><li id=\"field_6_372\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Palpitations<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_6_372'>\n\t\t\t<li class='gchoice gchoice_6_372_0'>\n\t\t\t\t<input name='input_372' type='radio' value='Never'  id='choice_6_372_0'    \/>\n\t\t\t\t<label for='choice_6_372_0' id='label_6_372_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_372_1'>\n\t\t\t\t<input name='input_372' type='radio' value='Occasional'  id='choice_6_372_1'    \/>\n\t\t\t\t<label for='choice_6_372_1' id='label_6_372_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_372_2'>\n\t\t\t\t<input name='input_372' type='radio' value='Frequent'  id='choice_6_372_2'    \/>\n\t\t\t\t<label for='choice_6_372_2' id='label_6_372_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_374\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rapid heart rate<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_6_374'>\n\t\t\t<li class='gchoice gchoice_6_374_0'>\n\t\t\t\t<input name='input_374' type='radio' value='Never'  id='choice_6_374_0'    \/>\n\t\t\t\t<label for='choice_6_374_0' id='label_6_374_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_374_1'>\n\t\t\t\t<input name='input_374' type='radio' value='Occasional'  id='choice_6_374_1'    \/>\n\t\t\t\t<label for='choice_6_374_1' id='label_6_374_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_374_2'>\n\t\t\t\t<input name='input_374' type='radio' value='Frequent'  id='choice_6_374_2'    \/>\n\t\t\t\t<label for='choice_6_374_2' id='label_6_374_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_375\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Chest pain<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_6_375'>\n\t\t\t<li class='gchoice gchoice_6_375_0'>\n\t\t\t\t<input name='input_375' type='radio' value='Never'  id='choice_6_375_0'    \/>\n\t\t\t\t<label for='choice_6_375_0' id='label_6_375_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_375_1'>\n\t\t\t\t<input name='input_375' type='radio' value='Occasional'  id='choice_6_375_1'    \/>\n\t\t\t\t<label for='choice_6_375_1' id='label_6_375_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_375_2'>\n\t\t\t\t<input name='input_375' type='radio' value='Frequent'  id='choice_6_375_2'    \/>\n\t\t\t\t<label for='choice_6_375_2' id='label_6_375_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_376\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >High blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_376'>\n\t\t\t<li class='gchoice gchoice_6_376_0'>\n\t\t\t\t<input name='input_376' type='radio' value='Never'  id='choice_6_376_0'    \/>\n\t\t\t\t<label for='choice_6_376_0' id='label_6_376_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_376_1'>\n\t\t\t\t<input name='input_376' type='radio' value='Occasional'  id='choice_6_376_1'    \/>\n\t\t\t\t<label for='choice_6_376_1' id='label_6_376_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_376_2'>\n\t\t\t\t<input name='input_376' type='radio' value='Frequent'  id='choice_6_376_2'    \/>\n\t\t\t\t<label for='choice_6_376_2' id='label_6_376_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_377\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Shortness of breath (with activity)<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_6_377'>\n\t\t\t<li class='gchoice gchoice_6_377_0'>\n\t\t\t\t<input name='input_377' type='radio' value='Never'  id='choice_6_377_0'    \/>\n\t\t\t\t<label for='choice_6_377_0' id='label_6_377_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_377_1'>\n\t\t\t\t<input name='input_377' type='radio' value='Occasional'  id='choice_6_377_1'    \/>\n\t\t\t\t<label for='choice_6_377_1' id='label_6_377_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_377_2'>\n\t\t\t\t<input name='input_377' type='radio' value='Frequent'  id='choice_6_377_2'    \/>\n\t\t\t\t<label for='choice_6_377_2' id='label_6_377_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_378\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Shortness of breath (lying down)<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_6_378'>\n\t\t\t<li class='gchoice gchoice_6_378_0'>\n\t\t\t\t<input name='input_378' type='radio' value='Never'  id='choice_6_378_0'    \/>\n\t\t\t\t<label for='choice_6_378_0' id='label_6_378_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_378_1'>\n\t\t\t\t<input name='input_378' type='radio' value='Occasional'  id='choice_6_378_1'    \/>\n\t\t\t\t<label for='choice_6_378_1' id='label_6_378_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_378_2'>\n\t\t\t\t<input name='input_378' type='radio' value='Frequent'  id='choice_6_378_2'    \/>\n\t\t\t\t<label for='choice_6_378_2' id='label_6_378_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_379\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Leg cramps (walking)<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_6_379'>\n\t\t\t<li class='gchoice gchoice_6_379_0'>\n\t\t\t\t<input name='input_379' type='radio' value='Never'  id='choice_6_379_0'    \/>\n\t\t\t\t<label for='choice_6_379_0' id='label_6_379_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_379_1'>\n\t\t\t\t<input name='input_379' type='radio' value='Occasional'  id='choice_6_379_1'    \/>\n\t\t\t\t<label for='choice_6_379_1' id='label_6_379_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_379_2'>\n\t\t\t\t<input name='input_379' type='radio' value='Frequent'  id='choice_6_379_2'    \/>\n\t\t\t\t<label for='choice_6_379_2' id='label_6_379_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_380\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Swollen feet\/ankles<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_6_380'>\n\t\t\t<li class='gchoice gchoice_6_380_0'>\n\t\t\t\t<input name='input_380' type='radio' value='Never'  id='choice_6_380_0'    \/>\n\t\t\t\t<label for='choice_6_380_0' id='label_6_380_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_380_1'>\n\t\t\t\t<input name='input_380' type='radio' value='Occasional'  id='choice_6_380_1'    \/>\n\t\t\t\t<label for='choice_6_380_1' id='label_6_380_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_380_2'>\n\t\t\t\t<input name='input_380' type='radio' value='Frequent'  id='choice_6_380_2'    \/>\n\t\t\t\t<label for='choice_6_380_2' id='label_6_380_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_381\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">CIRCULATION<\/h2><\/li><li id=\"field_6_382\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Varicose veins<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_6_382'>\n\t\t\t<li class='gchoice gchoice_6_382_0'>\n\t\t\t\t<input name='input_382' type='radio' value='Never'  id='choice_6_382_0'    \/>\n\t\t\t\t<label for='choice_6_382_0' id='label_6_382_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_382_1'>\n\t\t\t\t<input name='input_382' type='radio' value='Occasional'  id='choice_6_382_1'    \/>\n\t\t\t\t<label for='choice_6_382_1' id='label_6_382_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_382_2'>\n\t\t\t\t<input name='input_382' type='radio' value='Frequent'  id='choice_6_382_2'    \/>\n\t\t\t\t<label for='choice_6_382_2' id='label_6_382_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_383\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood clots<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_6_383'>\n\t\t\t<li class='gchoice gchoice_6_383_0'>\n\t\t\t\t<input name='input_383' type='radio' value='Never'  id='choice_6_383_0'    \/>\n\t\t\t\t<label for='choice_6_383_0' id='label_6_383_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_383_1'>\n\t\t\t\t<input name='input_383' type='radio' value='Occasional'  id='choice_6_383_1'    \/>\n\t\t\t\t<label for='choice_6_383_1' id='label_6_383_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_383_2'>\n\t\t\t\t<input name='input_383' type='radio' value='Frequent'  id='choice_6_383_2'    \/>\n\t\t\t\t<label for='choice_6_383_2' id='label_6_383_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_384\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Easy 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_6_384'>\n\t\t\t<li class='gchoice gchoice_6_384_0'>\n\t\t\t\t<input name='input_384' type='radio' value='Never'  id='choice_6_384_0'    \/>\n\t\t\t\t<label for='choice_6_384_0' id='label_6_384_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_384_1'>\n\t\t\t\t<input name='input_384' type='radio' value='Occasional'  id='choice_6_384_1'    \/>\n\t\t\t\t<label for='choice_6_384_1' id='label_6_384_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_384_2'>\n\t\t\t\t<input name='input_384' type='radio' value='Frequent'  id='choice_6_384_2'    \/>\n\t\t\t\t<label for='choice_6_384_2' id='label_6_384_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_385\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_385'>\n\t\t\t<li class='gchoice gchoice_6_385_0'>\n\t\t\t\t<input name='input_385' type='radio' value='Never'  id='choice_6_385_0'    \/>\n\t\t\t\t<label for='choice_6_385_0' id='label_6_385_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_385_1'>\n\t\t\t\t<input name='input_385' type='radio' value='Occasional'  id='choice_6_385_1'    \/>\n\t\t\t\t<label for='choice_6_385_1' id='label_6_385_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_385_2'>\n\t\t\t\t<input name='input_385' type='radio' value='Frequent'  id='choice_6_385_2'    \/>\n\t\t\t\t<label for='choice_6_385_2' id='label_6_385_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_386\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">SKIN<\/h2><\/li><li id=\"field_6_387\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pain<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_6_387'>\n\t\t\t<li class='gchoice gchoice_6_387_0'>\n\t\t\t\t<input name='input_387' type='radio' value='Never'  id='choice_6_387_0'    \/>\n\t\t\t\t<label for='choice_6_387_0' id='label_6_387_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_387_1'>\n\t\t\t\t<input name='input_387' type='radio' value='Occasional'  id='choice_6_387_1'    \/>\n\t\t\t\t<label for='choice_6_387_1' id='label_6_387_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_387_2'>\n\t\t\t\t<input name='input_387' type='radio' value='Frequent'  id='choice_6_387_2'    \/>\n\t\t\t\t<label for='choice_6_387_2' id='label_6_387_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_388\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Itching<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_6_388'>\n\t\t\t<li class='gchoice gchoice_6_388_0'>\n\t\t\t\t<input name='input_388' type='radio' value='Never'  id='choice_6_388_0'    \/>\n\t\t\t\t<label for='choice_6_388_0' id='label_6_388_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_388_1'>\n\t\t\t\t<input name='input_388' type='radio' value='Occasional'  id='choice_6_388_1'    \/>\n\t\t\t\t<label for='choice_6_388_1' id='label_6_388_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_388_2'>\n\t\t\t\t<input name='input_388' type='radio' value='Frequent'  id='choice_6_388_2'    \/>\n\t\t\t\t<label for='choice_6_388_2' id='label_6_388_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_389\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Dryness<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_6_389'>\n\t\t\t<li class='gchoice gchoice_6_389_0'>\n\t\t\t\t<input name='input_389' type='radio' value='Never'  id='choice_6_389_0'    \/>\n\t\t\t\t<label for='choice_6_389_0' id='label_6_389_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_389_1'>\n\t\t\t\t<input name='input_389' type='radio' value='Occasional'  id='choice_6_389_1'    \/>\n\t\t\t\t<label for='choice_6_389_1' id='label_6_389_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_389_2'>\n\t\t\t\t<input name='input_389' type='radio' value='Frequent'  id='choice_6_389_2'    \/>\n\t\t\t\t<label for='choice_6_389_2' id='label_6_389_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_390\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Eczema<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_6_390'>\n\t\t\t<li class='gchoice gchoice_6_390_0'>\n\t\t\t\t<input name='input_390' type='radio' value='Never'  id='choice_6_390_0'    \/>\n\t\t\t\t<label for='choice_6_390_0' id='label_6_390_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_390_1'>\n\t\t\t\t<input name='input_390' type='radio' value='Occasional'  id='choice_6_390_1'    \/>\n\t\t\t\t<label for='choice_6_390_1' id='label_6_390_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_390_2'>\n\t\t\t\t<input name='input_390' type='radio' value='Frequent'  id='choice_6_390_2'    \/>\n\t\t\t\t<label for='choice_6_390_2' id='label_6_390_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_391\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Rashes<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_6_391'>\n\t\t\t<li class='gchoice gchoice_6_391_0'>\n\t\t\t\t<input name='input_391' type='radio' value='Never'  id='choice_6_391_0'    \/>\n\t\t\t\t<label for='choice_6_391_0' id='label_6_391_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_391_1'>\n\t\t\t\t<input name='input_391' type='radio' value='Occasional'  id='choice_6_391_1'    \/>\n\t\t\t\t<label for='choice_6_391_1' id='label_6_391_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_391_2'>\n\t\t\t\t<input name='input_391' type='radio' value='Frequent'  id='choice_6_391_2'    \/>\n\t\t\t\t<label for='choice_6_391_2' id='label_6_391_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_392\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">GASTROINTESTINAL<\/h2><\/li><li id=\"field_6_393\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Regurgitation<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_6_393'>\n\t\t\t<li class='gchoice gchoice_6_393_0'>\n\t\t\t\t<input name='input_393' type='radio' value='Never'  id='choice_6_393_0'    \/>\n\t\t\t\t<label for='choice_6_393_0' id='label_6_393_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_393_1'>\n\t\t\t\t<input name='input_393' type='radio' value='Occasional'  id='choice_6_393_1'    \/>\n\t\t\t\t<label for='choice_6_393_1' id='label_6_393_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_393_2'>\n\t\t\t\t<input name='input_393' type='radio' value='Frequent'  id='choice_6_393_2'    \/>\n\t\t\t\t<label for='choice_6_393_2' id='label_6_393_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_394\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Ulcers<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_6_394'>\n\t\t\t<li class='gchoice gchoice_6_394_0'>\n\t\t\t\t<input name='input_394' type='radio' value='Never'  id='choice_6_394_0'    \/>\n\t\t\t\t<label for='choice_6_394_0' id='label_6_394_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_394_1'>\n\t\t\t\t<input name='input_394' type='radio' value='Occasional'  id='choice_6_394_1'    \/>\n\t\t\t\t<label for='choice_6_394_1' id='label_6_394_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_394_2'>\n\t\t\t\t<input name='input_394' type='radio' value='Frequent'  id='choice_6_394_2'    \/>\n\t\t\t\t<label for='choice_6_394_2' id='label_6_394_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_395\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Abdominal pain<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_6_395'>\n\t\t\t<li class='gchoice gchoice_6_395_0'>\n\t\t\t\t<input name='input_395' type='radio' value='Never'  id='choice_6_395_0'    \/>\n\t\t\t\t<label for='choice_6_395_0' id='label_6_395_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_395_1'>\n\t\t\t\t<input name='input_395' type='radio' value='Occasional'  id='choice_6_395_1'    \/>\n\t\t\t\t<label for='choice_6_395_1' id='label_6_395_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_395_2'>\n\t\t\t\t<input name='input_395' type='radio' value='Frequent'  id='choice_6_395_2'    \/>\n\t\t\t\t<label for='choice_6_395_2' id='label_6_395_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_396\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Nausea<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_6_396'>\n\t\t\t<li class='gchoice gchoice_6_396_0'>\n\t\t\t\t<input name='input_396' type='radio' value='Never'  id='choice_6_396_0'    \/>\n\t\t\t\t<label for='choice_6_396_0' id='label_6_396_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_396_1'>\n\t\t\t\t<input name='input_396' type='radio' value='Occasional'  id='choice_6_396_1'    \/>\n\t\t\t\t<label for='choice_6_396_1' id='label_6_396_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_396_2'>\n\t\t\t\t<input name='input_396' type='radio' value='Frequent'  id='choice_6_396_2'    \/>\n\t\t\t\t<label for='choice_6_396_2' id='label_6_396_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_397\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Vomiting<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_6_397'>\n\t\t\t<li class='gchoice gchoice_6_397_0'>\n\t\t\t\t<input name='input_397' type='radio' value='Never'  id='choice_6_397_0'    \/>\n\t\t\t\t<label for='choice_6_397_0' id='label_6_397_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_397_1'>\n\t\t\t\t<input name='input_397' type='radio' value='Occasional'  id='choice_6_397_1'    \/>\n\t\t\t\t<label for='choice_6_397_1' id='label_6_397_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_397_2'>\n\t\t\t\t<input name='input_397' type='radio' value='Frequent'  id='choice_6_397_2'    \/>\n\t\t\t\t<label for='choice_6_397_2' id='label_6_397_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_398\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Diarrhea (frequent)<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_6_398'>\n\t\t\t<li class='gchoice gchoice_6_398_0'>\n\t\t\t\t<input name='input_398' type='radio' value='Never'  id='choice_6_398_0'    \/>\n\t\t\t\t<label for='choice_6_398_0' id='label_6_398_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_398_1'>\n\t\t\t\t<input name='input_398' type='radio' value='Occasional'  id='choice_6_398_1'    \/>\n\t\t\t\t<label for='choice_6_398_1' id='label_6_398_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_398_2'>\n\t\t\t\t<input name='input_398' type='radio' value='Frequent'  id='choice_6_398_2'    \/>\n\t\t\t\t<label for='choice_6_398_2' id='label_6_398_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_399\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Constipation<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_6_399'>\n\t\t\t<li class='gchoice gchoice_6_399_0'>\n\t\t\t\t<input name='input_399' type='radio' value='Never'  id='choice_6_399_0'    \/>\n\t\t\t\t<label for='choice_6_399_0' id='label_6_399_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_399_1'>\n\t\t\t\t<input name='input_399' type='radio' value='Occasional'  id='choice_6_399_1'    \/>\n\t\t\t\t<label for='choice_6_399_1' id='label_6_399_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_399_2'>\n\t\t\t\t<input name='input_399' type='radio' value='Frequent'  id='choice_6_399_2'    \/>\n\t\t\t\t<label for='choice_6_399_2' id='label_6_399_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_400\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Blood in stool<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_6_400'>\n\t\t\t<li class='gchoice gchoice_6_400_0'>\n\t\t\t\t<input name='input_400' type='radio' value='Never'  id='choice_6_400_0'    \/>\n\t\t\t\t<label for='choice_6_400_0' id='label_6_400_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_400_1'>\n\t\t\t\t<input name='input_400' type='radio' value='Occasional'  id='choice_6_400_1'    \/>\n\t\t\t\t<label for='choice_6_400_1' id='label_6_400_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_400_2'>\n\t\t\t\t<input name='input_400' type='radio' value='Frequent'  id='choice_6_400_2'    \/>\n\t\t\t\t<label for='choice_6_400_2' id='label_6_400_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_401\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hepatitis<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_6_401'>\n\t\t\t<li class='gchoice gchoice_6_401_0'>\n\t\t\t\t<input name='input_401' type='radio' value='Never'  id='choice_6_401_0'    \/>\n\t\t\t\t<label for='choice_6_401_0' id='label_6_401_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_401_1'>\n\t\t\t\t<input name='input_401' type='radio' value='Occasional'  id='choice_6_401_1'    \/>\n\t\t\t\t<label for='choice_6_401_1' id='label_6_401_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_401_2'>\n\t\t\t\t<input name='input_401' type='radio' value='Frequent'  id='choice_6_401_2'    \/>\n\t\t\t\t<label for='choice_6_401_2' id='label_6_401_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_402\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pancreatitis<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_6_402'>\n\t\t\t<li class='gchoice gchoice_6_402_0'>\n\t\t\t\t<input name='input_402' type='radio' value='Never'  id='choice_6_402_0'    \/>\n\t\t\t\t<label for='choice_6_402_0' id='label_6_402_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_402_1'>\n\t\t\t\t<input name='input_402' type='radio' value='Occasional'  id='choice_6_402_1'    \/>\n\t\t\t\t<label for='choice_6_402_1' id='label_6_402_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_402_2'>\n\t\t\t\t<input name='input_402' type='radio' value='Frequent'  id='choice_6_402_2'    \/>\n\t\t\t\t<label for='choice_6_402_2' id='label_6_402_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_439\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >COVID 19 Vaccination<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_6_439'>\n\t\t\t<li class='gchoice gchoice_6_439_0'>\n\t\t\t\t<input name='input_439' type='radio' value='No'  id='choice_6_439_0'    \/>\n\t\t\t\t<label for='choice_6_439_0' id='label_6_439_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_439_1'>\n\t\t\t\t<input name='input_439' type='radio' value='Yes'  id='choice_6_439_1'    \/>\n\t\t\t\t<label for='choice_6_439_1' id='label_6_439_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_403\" class=\"gfield gfield--type-section gfield--input-type-section gsection gf-noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">FEMALES ONLY<\/h2><\/li><li id=\"field_6_404\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_first_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Painful menstruation<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_6_404'>\n\t\t\t<li class='gchoice gchoice_6_404_0'>\n\t\t\t\t<input name='input_404' type='radio' value='Never'  id='choice_6_404_0'    \/>\n\t\t\t\t<label for='choice_6_404_0' id='label_6_404_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_404_1'>\n\t\t\t\t<input name='input_404' type='radio' value='Occasional'  id='choice_6_404_1'    \/>\n\t\t\t\t<label for='choice_6_404_1' id='label_6_404_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_404_2'>\n\t\t\t\t<input name='input_404' type='radio' value='Frequent'  id='choice_6_404_2'    \/>\n\t\t\t\t<label for='choice_6_404_2' id='label_6_404_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_405\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_second_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >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_6_405'>\n\t\t\t<li class='gchoice gchoice_6_405_0'>\n\t\t\t\t<input name='input_405' type='radio' value='Yes'  id='choice_6_405_0'    \/>\n\t\t\t\t<label for='choice_6_405_0' id='label_6_405_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_6_405_1'>\n\t\t\t\t<input name='input_405' type='radio' value='No'  id='choice_6_405_1'    \/>\n\t\t\t\t<label for='choice_6_405_1' id='label_6_405_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_406\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_third_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Pelvic pap smear<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_6_406'>\n\t\t\t<li class='gchoice gchoice_6_406_0'>\n\t\t\t\t<input name='input_406' type='radio' value='Never'  id='choice_6_406_0'    \/>\n\t\t\t\t<label for='choice_6_406_0' id='label_6_406_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_406_1'>\n\t\t\t\t<input name='input_406' type='radio' value='Occasional'  id='choice_6_406_1'    \/>\n\t\t\t\t<label for='choice_6_406_1' id='label_6_406_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_406_2'>\n\t\t\t\t<input name='input_406' type='radio' value='Frequent'  id='choice_6_406_2'    \/>\n\t\t\t\t<label for='choice_6_406_2' id='label_6_406_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_407\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_fourth_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Hot flashes<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_6_407'>\n\t\t\t<li class='gchoice gchoice_6_407_0'>\n\t\t\t\t<input name='input_407' type='radio' value='Never'  id='choice_6_407_0'    \/>\n\t\t\t\t<label for='choice_6_407_0' id='label_6_407_0' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_407_1'>\n\t\t\t\t<input name='input_407' type='radio' value='Occasional'  id='choice_6_407_1'    \/>\n\t\t\t\t<label for='choice_6_407_1' id='label_6_407_1' class='gform-field-label gform-field-label--type-inline'>Occasional<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_407_2'>\n\t\t\t\t<input name='input_407' type='radio' value='Frequent'  id='choice_6_407_2'    \/>\n\t\t\t\t<label for='choice_6_407_2' id='label_6_407_2' class='gform-field-label gform-field-label--type-inline'>Frequent<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_6' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_6' id='gform_theme_6' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_6' id='gform_style_settings_6' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='EUR' value='pEALjAg9hqyRWBWJvJdOhDfsbtJ2C8eYQZvwkkzapFBVymKPD2MzzLeXFDlazFHfldaMkZQEs8+mOeQWjYMPs5qwtoY8vFXNo9q07V0XGS0HjhE=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='WyJ7XCIxMS4xXCI6XCIzYWRlOTI4OTY1ZTAwMjVmOTQyNGNiNWZiZmI5YmIyY1wiLFwiMTEuMlwiOlwiNTc0ZDI3NjgzOTIwYTAwY2JlYzhjZTA1NzIxMWMzOTlcIixcIjExLjNcIjpcImI0MWJlYzA3MTc5ODBlNDFmNWU5MmQ0NTY0MmEwMGY0XCIsXCIxNi4xXCI6XCIzYWRlOTI4OTY1ZTAwMjVmOTQyNGNiNWZiZmI5YmIyY1wiLFwiMTYuMlwiOlwiMWFkZWE4NjQ3NGU5OWFiNDZmNmNhMzMzOGUzMmM1ZjBcIixcIjE2LjNcIjpcImI0MWJlYzA3MTc5ODBlNDFmNWU5MmQ0NTY0MmEwMGY0XCJ9IiwiNWRjNGY5ZGVkZmNiOGJmMDUyMTI1NGIxMDAwYmJjN2MiXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/oreme.eu\/wp-content\/uploads\/2019\/08\/loading.gif', true );jQuery('#gform_ajax_frame_6').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_6');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_6').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', 0);jQuery('#gform_wrapper_6').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_6').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_6').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_6').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_6').val();gformInitSpinner( 6, 'https:\/\/oreme.eu\/wp-content\/uploads\/2019\/08\/loading.gif', true );jQuery(document).trigger('gform_page_loaded', [6, current_page]);window['gf_submitting_6'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_6').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_6').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [6]);window['gf_submitting_6'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_6').text());}else{jQuery('#gform_6').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"6\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_6\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_6\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_6\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 6, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n<p>Sonderf\u00e4lle, wie Post-Krebs-Patienten, k\u00f6nnten um weitere medizinische Untersuchungsergebnisse gebeten werden.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2m2zxk-2b81e9850d28ff77af4db9b50423990b'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-7' data-fake-id='#toggle-id-7' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-7' data-slide-speed=\"200\" data-title=\"Ich lebe nicht in der Schweiz, kann ich mich dennoch beraten und behandeln lassen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Ich lebe nicht in der Schweiz, kann ich mich dennoch beraten und behandeln lassen?\" data-aria_expanded=\"Click to collapse: Ich lebe nicht in der Schweiz, kann ich mich dennoch beraten und behandeln lassen?\">Ich lebe nicht in der Schweiz, kann ich mich dennoch beraten und behandeln lassen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-7' aria-labelledby='toggle-toggle-id-7' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p><strong>Kann ich mich behandeln lassen?<\/strong><\/p>\n<p>Ja! Wir behandeln Patienten aus ganz Europa, dem Nahen Osten, der arabischen Halbinsel und Afrika.<\/p>\n<p><strong>Kann ich eine Online-Konsultation haben?<\/strong><\/p>\n<p>Ja! Online-Konsultationen k\u00f6nnen stattfinden, sobald uns alle erforderlichen Unterlagen vorliegen<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54k7og-21d76f499a19e5ad698cb67a79e0e23a'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-8' data-fake-id='#toggle-id-8' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-8' data-slide-speed=\"200\" data-title=\"R\u00f6ntgen vs. MRT: Warum ben\u00f6tigen Sie MRT-Bilder?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: R\u00f6ntgen vs. MRT: Warum ben\u00f6tigen Sie MRT-Bilder?\" data-aria_expanded=\"Click to collapse: R\u00f6ntgen vs. MRT: Warum ben\u00f6tigen Sie MRT-Bilder?\">R\u00f6ntgen vs. MRT: Warum ben\u00f6tigen Sie MRT-Bilder?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-8' aria-labelledby='toggle-toggle-id-8' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Im Gegensatz zu R\u00f6ntgenbildern, die haupts\u00e4chlich Knochen darstellen, erm\u00f6glicht ein MRT-Bild eine 3D-Darstellung des Knochens und der Weichteile. Wenn eine Verletzung vorliegt, m\u00fcssen sowohl der Knochen als auch das Weichgewebe untersucht und, falls erforderlich, behandelt werden um optimale Ergebnisse bei einer regenerativen Behandlung zu erzielen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54jpbh-b7928a9068e7073577e2bc077b870d22'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-9' data-fake-id='#toggle-id-9' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-9' data-slide-speed=\"200\" data-title=\"Meine MRT-Bilder sind \u00e4lter als 6 Monate. Ist das in Ordnung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Meine MRT-Bilder sind \u00e4lter als 6 Monate. Ist das in Ordnung?\" data-aria_expanded=\"Click to collapse: Meine MRT-Bilder sind \u00e4lter als 6 Monate. Ist das in Ordnung?\">Meine MRT-Bilder sind \u00e4lter als 6 Monate. Ist das in Ordnung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-9' aria-labelledby='toggle-toggle-id-9' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Der Arzt ben\u00f6tigt die aktuellsten verf\u00fcgbaren MRT-Aufnahmen.<br \/>\nDie MRT-Aufnahmen sollten postoperativ, gegebenenfalls ohne Kontrastmittel und weniger als 6 Monate alt sein.<br \/>\nWarum? Einige Verletzungen, z.B. eine H\u00fcftarthrose, kann sich in wenigen Monaten bis zu zwei Jahren entwickeln.<br \/>\nJe neuer also das MRT, desto besser ist die Diagnose Ihres aktuellen Zustands.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54j5yw-992f15f62ed113eb3acb81a5fefa4ad4'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-10' data-fake-id='#toggle-id-10' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-10' data-slide-speed=\"200\" data-title=\"Kein MRT?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Kein MRT?\" data-aria_expanded=\"Click to collapse: Kein MRT?\">Kein MRT?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-10' aria-labelledby='toggle-toggle-id-10' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Gerne helfen wir Ihnen mit einer MRT-\u00dcberweisung. Um eine zu erhalten, m\u00fcssen Sie das Kandidaten- und Patientenformular ausf\u00fcllen, in dem Ihre Krankengeschichte aufgef\u00fchrt wird.<\/p>\n<p><strong>Wichtiger Hinweis:<\/strong> Bitte beachten Sie, dass nationale Krankenversicherungen in einigen L\u00e4ndern die Kosten f\u00fcr\u00a0 MRT-Untersuchungen nicht decken, die von einem Arzt im Ausland angewiesen werden. In solchen F\u00e4llen tr\u00e4gt der Patient alle Kosten, die durch die MRT-Untersuchung entstehen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54if0j-bc05a64ed7769bd3347ef9d37961c0dc'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-11' data-fake-id='#toggle-id-11' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-11' data-slide-speed=\"200\" data-title=\"Sie haben ein Metallimplantat? Wir beraten Sie gerne \u00fcber MRT-Alternativen!\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Sie haben ein Metallimplantat? Wir beraten Sie gerne \u00fcber MRT-Alternativen!\" data-aria_expanded=\"Click to collapse: Sie haben ein Metallimplantat? Wir beraten Sie gerne \u00fcber MRT-Alternativen!\">Sie haben ein Metallimplantat? Wir beraten Sie gerne \u00fcber MRT-Alternativen!<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-11' aria-labelledby='toggle-toggle-id-11' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Lassen Sie uns wissen, welche Art von Metallimplantat Sie haben. Ein 3D-CT-Scan k\u00f6nnte im Ausnahmezustand iausreichen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2m47hv-0d6586b13905590e16b054c42ace50d0'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-12' data-fake-id='#toggle-id-12' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-12' data-slide-speed=\"200\" data-title=\"Wie kann ich meine MRT-Bilder \u00fcbermitteln?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie kann ich meine MRT-Bilder \u00fcbermitteln?\" data-aria_expanded=\"Click to collapse: Wie kann ich meine MRT-Bilder \u00fcbermitteln?\">Wie kann ich meine MRT-Bilder \u00fcbermitteln?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-12' aria-labelledby='toggle-toggle-id-12' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Sie k\u00f6nnen uns eine CD bzw. USB-Stick mit den MRT-Bildern in einem wattiertem Umschlag per Post zukommen lassen. Unsere Anschrift:<\/p>\n<p>Dr. Rolandas Janu\u0161as<br \/>\nOreme<br \/>\nHauptstrasse 2<br \/>\nCH-9053 Teufen<br \/>\nSchweiz<\/p>\n<p>Alternativ k\u00f6nnen Sie uns die Bilder per WeTransfer online zukommen lassen. Daf\u00fcr <a href=\"https:\/\/oreme.eu\/de\/mrt-dateien-hochladen\/\" target=\"_blank\" rel=\"noopener noreferrer\">klicken Sie bitte hier<\/a>.<\/p>\n<p>Bitte beachten Sie, dass andere \u00dcbermittlungsmethoden (DropBox, GoogleDrive etc.) derzeit nicht akzeptiert werden.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54ez4g-ee8f1d204d42a37f46bd45dae2d65352'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-13' data-fake-id='#toggle-id-13' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-13' data-slide-speed=\"200\" data-title=\"Sind meine Daten bei WeTransfer sicher?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Sind meine Daten bei WeTransfer sicher?\" data-aria_expanded=\"Click to collapse: Sind meine Daten bei WeTransfer sicher?\">Sind meine Daten bei WeTransfer sicher?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-13' aria-labelledby='toggle-toggle-id-13' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Bitte beachten Sie, dass wir alle notwendigen Vorkehrungen treffen, um die privaten Daten unserer Patienten bestm\u00f6glichst zu sichern.<br \/>\nPatienten sollten sich dar\u00fcber im Klaren sein, dass alle Cloudservices das Risiko erh\u00f6hen, dass ihre Datenschutzrechte verletzt werden. Bitte informieren Sie sich \u00fcber die &#8222;Datenschutzerkl\u00e4rungen&#8220; des Online-Datentransferanbieters, die in der Regel unter &#8222;Allgemeine Gesch\u00e4ftsbedingungen&#8220; aufgef\u00fchrt sind.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54egbr-06d84f84d27bb9d9afaeb866a5115db2'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-14' data-fake-id='#toggle-id-14' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-14' data-slide-speed=\"200\" data-title=\"Gibt es eine Garantie auf Verbesserung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Gibt es eine Garantie auf Verbesserung?\" data-aria_expanded=\"Click to collapse: Gibt es eine Garantie auf Verbesserung?\">Gibt es eine Garantie auf Verbesserung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-14' aria-labelledby='toggle-toggle-id-14' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Leider nein. Wie bei jedem medizinischen Eingriff k\u00f6nnen wir die F\u00e4higkeit Ihres K\u00f6rpers, sich selbst zu 100% zu heilen, nicht garantieren. Der Arzt wird Ihnen eine Einsch\u00e4tzung Ihres Eignungsgrades f\u00fcr Verfahren und die M\u00f6glichkeit dies zu verbessern geben.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54dceo-46783248ee7cad05864bb3ab3f48d018'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-15' data-fake-id='#toggle-id-15' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-15' data-slide-speed=\"200\" data-title=\"Was besagen die Eignungsgrade?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Was besagen die Eignungsgrade?\" data-aria_expanded=\"Click to collapse: Was besagen die Eignungsgrade?\">Was besagen die Eignungsgrade?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-15' aria-labelledby='toggle-toggle-id-15' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p><strong>Gut<\/strong> wird definiert als eine 2\/3 Wahrscheinlichkeit, dass die Behandlung eine positive Wirkung haben wird. Unter &#8222;positiver Wirkung&#8220; verstehen wir, dass Patienten berichten, die Behandlung habe die Schmerzen bedeutsam verringert und\/oder Ihre Funktionsf\u00e4higkeit bedeutsam gesteigert. In diesem Sinne bedeutet <strong>M\u00e4\u00dfig<\/strong> eine 50\/50 Wahrscheinlichkeit einer positiven Wirkung und <strong>Gering<\/strong> eine 1\/3 oder bessere Wahrscheinlichkeit.<\/p>\n<p>Achtung: wir beraten und haben die volle M\u00f6glichkeit in der Klinik Ihre Gesundheit deutlich zu verbessern, besonders in der Kooperation mit <a href=\"http:\/\/www.biologische-Tagesklinik.ch\">biologischen Tagesklinik Dr. Rupp<\/a><\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2m6g3j-210ae9dd20ac519b1a5c3c9ee3d9d6fe'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-16' data-fake-id='#toggle-id-16' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-16' data-slide-speed=\"200\" data-title=\"Mir wurde ein geringer Eignungsgrad bescheinigt. Soll ich mich nicht behandeln lassen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Mir wurde ein geringer Eignungsgrad bescheinigt. Soll ich mich nicht behandeln lassen?\" data-aria_expanded=\"Click to collapse: Mir wurde ein geringer Eignungsgrad bescheinigt. Soll ich mich nicht behandeln lassen?\">Mir wurde ein geringer Eignungsgrad bescheinigt. Soll ich mich nicht behandeln lassen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-16' aria-labelledby='toggle-toggle-id-16' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Nein, es bedeutet nur, dass wir erwarten, dass Ihre Heilung weniger erfolgreich ist. Es gibt aber auch Erfolgsgeschichten von Patienten, die beschlossen haben, trotz geringer Erfolgsaussichten mit der Behandlung fortzufahren. Lassen Sie sich nicht entmutigen!<\/p>\n<p>Zweitens,- wir beraten immer die Patienten wie sie die Chancen der Heilung erheblich erh\u00f6hen k\u00f6nnen!<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn548d7h-f0d397cd7661f2ead7b289a120d8c528'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-17' data-fake-id='#toggle-id-17' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-17' data-slide-speed=\"200\" data-title=\"Gibt es eine Altersbeschr\u00e4nkung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Gibt es eine Altersbeschr\u00e4nkung?\" data-aria_expanded=\"Click to collapse: Gibt es eine Altersbeschr\u00e4nkung?\">Gibt es eine Altersbeschr\u00e4nkung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-17' aria-labelledby='toggle-toggle-id-17' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Nein. Ihr Alter wird als Teil Ihrer medizinischen Geschichte betrachtet, gilt aber nicht als Ausschlusskriterium.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn5484vz-8c38974613ff0aec93e85061c777229a'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-18' data-fake-id='#toggle-id-18' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-18' data-slide-speed=\"200\" data-title=\"Kann ich meherere Verletzungen in einer Sitzung behandeln lassen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Kann ich meherere Verletzungen in einer Sitzung behandeln lassen?\" data-aria_expanded=\"Click to collapse: Kann ich meherere Verletzungen in einer Sitzung behandeln lassen?\">Kann ich meherere Verletzungen in einer Sitzung behandeln lassen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-18' aria-labelledby='toggle-toggle-id-18' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>In einigen F\u00e4llen ja. Dies wird vom Arzt w\u00e4hrend der Konsultation festgelegt.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn547ulu-715716c538b01df648a64cf17652d978'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-19' data-fake-id='#toggle-id-19' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-19' data-slide-speed=\"200\" data-title=\"Mein bisheriger Arzt \u00e4u\u00dfert sich skeptisch \u00fcber solche Verfahren!\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Mein bisheriger Arzt \u00e4u\u00dfert sich skeptisch \u00fcber solche Verfahren!\" data-aria_expanded=\"Click to collapse: Mein bisheriger Arzt \u00e4u\u00dfert sich skeptisch \u00fcber solche Verfahren!\">Mein bisheriger Arzt \u00e4u\u00dfert sich skeptisch \u00fcber solche Verfahren!<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-19' aria-labelledby='toggle-toggle-id-19' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Oft \u00e4u\u00dfern sich \u00c4rzte skeptisch, da sie die Vorteile der ganzheitlichen und regenerativen Behandlung und ihrer Behandlungsmethoden nicht kennen. Bitte sprechen Sie \u00fcber diese Bedenken mit unserem Arzt, er verf\u00fcgt \u00fcber das n\u00f6tige Fachwissen aus der Orthop\u00e4die und der Wirbels\u00e4ulenchirurgie.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn54775p-624ea974aefe694737b7c56b8d434fc1'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-20' data-fake-id='#toggle-id-20' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-20' data-slide-speed=\"200\" data-title=\"Gibt es ein erh\u00f6htes Krebsrisiko?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Gibt es ein erh\u00f6htes Krebsrisiko?\" data-aria_expanded=\"Click to collapse: Gibt es ein erh\u00f6htes Krebsrisiko?\">Gibt es ein erh\u00f6htes Krebsrisiko?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-20' aria-labelledby='toggle-toggle-id-20' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Bislang konnte bei den von uns eingesetzten Verfahren kein erh\u00f6htes Risiko f\u00fcr Zellmutationen festgestellt werden.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn546xa2-201c5771dd5c7b6a1aaec1c590f404ea'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-21' data-fake-id='#toggle-id-21' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-21' data-slide-speed=\"200\" data-title=\"Bietet Ihre Klinik PRP-Injektion an?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Bietet Ihre Klinik PRP-Injektion an?\" data-aria_expanded=\"Click to collapse: Bietet Ihre Klinik PRP-Injektion an?\">Bietet Ihre Klinik PRP-Injektion an?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-21' aria-labelledby='toggle-toggle-id-21' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Unsere Klinik f\u00fchrt eine perfektionierte PRP-Infiltrationsbehandlung durch.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2m7odh-fbbb972c530d6014fb83045da38aaea8'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-22' data-fake-id='#toggle-id-22' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-22' data-slide-speed=\"200\" data-title=\"Reicht eine lokale An\u00e4sthesie oder brauche ich eine Vollnarkose?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Reicht eine lokale An\u00e4sthesie oder brauche ich eine Vollnarkose?\" data-aria_expanded=\"Click to collapse: Reicht eine lokale An\u00e4sthesie oder brauche ich eine Vollnarkose?\">Reicht eine lokale An\u00e4sthesie oder brauche ich eine Vollnarkose?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-22' aria-labelledby='toggle-toggle-id-22' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Meist reicht ein Lokalan\u00e4sthetikum vollkommen aus. In speziellen F\u00e4llen f\u00fchren wir die Behandlung unter Sedierung durch.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-av_toggle-e80e47f331c36871353efc29624f3874'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-23' data-fake-id='#toggle-id-23' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-23' data-slide-speed=\"200\" data-title=\"Was ist die Paleo-Di\u00e4t?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Was ist die Paleo-Di\u00e4t?\" data-aria_expanded=\"Click to collapse: Was ist die Paleo-Di\u00e4t?\">Was ist die Paleo-Di\u00e4t?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-23' aria-labelledby='toggle-toggle-id-23' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Vor einem Eingriff mit unseren Verfahren empfehlen wir die Paleo-Di\u00e4t.\u00a0Auch bekannt als &#8222;H\u00f6hlenmenschen-Di\u00e4t&#8220; ist die\u00a0Paleo-Di\u00e4t nach unserer Ansicht der schnellste Weg zu einer erfolgreichen Stammzellen-Behandlung. Es handelt sich dabei um den Verzicht auf Alkohol, Zucker, Milchprodukte und verarbeitete Lebensmittel, wie Brot und Backwaren. Sie k\u00f6nnen organisches Gem\u00fcse und Saison-Obst sowie Fisch und Fleisch essen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn545l81-8d50537231340c00bdbb7616af108adf'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-24' data-fake-id='#toggle-id-24' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-24' data-slide-speed=\"200\" data-title=\"Warum Paleo?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Warum Paleo?\" data-aria_expanded=\"Click to collapse: Warum Paleo?\">Warum Paleo?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-24' aria-labelledby='toggle-toggle-id-24' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Der K\u00f6rper eines Patienten muss nach dem Eingriff auf Heilung vorbereitet werden.<\/p>\n<p>Die Hauptursachen f\u00fcr chronische Krankheiten sind Ern\u00e4hrung, Inaktivit\u00e4t und Stress.<\/p>\n<p>Schlechte Di\u00e4ten verursachen chronische Darmentz\u00fcndungen.<\/p>\n<p>Eine solche Entz\u00fcndung reduziert die F\u00e4higkeit des K\u00f6rpers, ben\u00f6tigte N\u00e4hrstoffe zu absorbieren und gegen die chronische Darmentz\u00fcndung zu &#8222;k\u00e4mpfen&#8220;. Der K\u00f6rper sollte sich darauf konzentrieren, Ihre tats\u00e4chlich verletzten Stellen zu heilen, wie Ihre Wirbels\u00e4ule, Kniegelenke usw.<\/p>\n<p>Die Paleo-Di\u00e4t reduziert erfolgreich die Darmentz\u00fcndung.<br \/>\nWir haben eine Verbesserung der allgemeinen Gesundheit der Patienten (z.B. reduzierte Schmerzen im unteren R\u00fcckenbereich) nach einer Prolotherapie und einem einfachen Wechsel zu einer Paleo-Di\u00e4t beobachtet. Daher weisen wir alle unsere Patienten an, Paleo f\u00fcr die Zwecke unserer regenerativen Behandlungen zu verwenden, sei es die PRP (aus Blut) oder die Stammzellen-Therapie.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn544692-a52ee6e3fb13b6c91f3d614b4fe22678'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-25' data-fake-id='#toggle-id-25' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-25' data-slide-speed=\"200\" data-title=\"Wie lange dauert die Paleo-Di\u00e4t?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie lange dauert die Paleo-Di\u00e4t?\" data-aria_expanded=\"Click to collapse: Wie lange dauert die Paleo-Di\u00e4t?\">Wie lange dauert die Paleo-Di\u00e4t?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-25' aria-labelledby='toggle-toggle-id-25' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Mindestens 3-4 Wochen vor der Behandlung und mindestens 6 Wochen nach der Behandlung. Wir empfehlen jedoch diese Ern\u00e4hrungsform als Lebensstil beizubehalten \ud83d\ude09<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn5428n8-44158de8502ae415b786573e886ea90b'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-26' data-fake-id='#toggle-id-26' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-26' data-slide-speed=\"200\" data-title=\"Hilft mir Paleo Gewicht zu verlieren?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Hilft mir Paleo Gewicht zu verlieren?\" data-aria_expanded=\"Click to collapse: Hilft mir Paleo Gewicht zu verlieren?\">Hilft mir Paleo Gewicht zu verlieren?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-26' aria-labelledby='toggle-toggle-id-26' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Die Paleo-Di\u00e4t wirkt sich postiv auf Ihr Gewicht aus. Paleo erlaubt Ihnen so viel zu essen wie Sie m\u00f6chten.<br \/>\nEine gro\u00dfe Hilfe sind die zahlreichen Paleo-Online-Rezepte.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn541uk9-8aca452d6e5751afecfba763656225b0'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-27' data-fake-id='#toggle-id-27' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-27' data-slide-speed=\"200\" data-title=\"Wo kann ich mehr Information zu Paleo erhalten?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wo kann ich mehr Information zu Paleo erhalten?\" data-aria_expanded=\"Click to collapse: Wo kann ich mehr Information zu Paleo erhalten?\">Wo kann ich mehr Information zu Paleo erhalten?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-27' aria-labelledby='toggle-toggle-id-27' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Suchen Sie einfach im Internet oder fragen Sie bei uns nach. Wir empfehlen besonders www.paleo360.de<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2m9b9i-8b25cdfdf3f962377bb40b2bc3bbed4d'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-28' data-fake-id='#toggle-id-28' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-28' data-slide-speed=\"200\" data-title=\"Wann soll ich vor einer Behandlung nichts essen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wann soll ich vor einer Behandlung nichts essen?\" data-aria_expanded=\"Click to collapse: Wann soll ich vor einer Behandlung nichts essen?\">Wann soll ich vor einer Behandlung nichts essen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-28' aria-labelledby='toggle-toggle-id-28' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>N\u00fcchtern m\u00fcssen Patienten in bestimmten F\u00e4llen sein, wie z. B. die transorale zervikale Bahandlung, die unter Vollnarkose durchgef\u00fchrt wird.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn540r8n-4ffae149f7246dda822245f22ad1cc66'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-29' data-fake-id='#toggle-id-29' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-29' data-slide-speed=\"200\" data-title=\"Wie lange dauert eine Stammzellen-Behandlung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie lange dauert eine Stammzellen-Behandlung?\" data-aria_expanded=\"Click to collapse: Wie lange dauert eine Stammzellen-Behandlung?\">Wie lange dauert eine Stammzellen-Behandlung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-29' aria-labelledby='toggle-toggle-id-29' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Meistens werden solche Prozeduren (mit Ausnahme von Wirbels\u00e4ulenbehandlungen) an 3 separaten Tagen durchgef\u00fchrt, die sich \u00fcber eine Woche erstrecken.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn5400nt-a54af33e8971ac20942cf350f971f4a3'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-30' data-fake-id='#toggle-id-30' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-30' data-slide-speed=\"200\" data-title=\"Wie lange dauert eine PRP Behandlung?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie lange dauert eine PRP Behandlung?\" data-aria_expanded=\"Click to collapse: Wie lange dauert eine PRP Behandlung?\">Wie lange dauert eine PRP Behandlung?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-30' aria-labelledby='toggle-toggle-id-30' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Meistens sind solche Eingriffe (einschlie\u00dflich Wirbels\u00e4ulenbehandlungen) innerhalb eines einzigen Tages abgeschlossen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53zrwh-c3193f37f4419553eb63470d563cad76'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-31' data-fake-id='#toggle-id-31' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-31' data-slide-speed=\"200\" data-title=\"Wie lange dauert eine Stammzellenbehandlung an der Wirbels\u00e4ule?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie lange dauert eine Stammzellenbehandlung an der Wirbels\u00e4ule?\" data-aria_expanded=\"Click to collapse: Wie lange dauert eine Stammzellenbehandlung an der Wirbels\u00e4ule?\">Wie lange dauert eine Stammzellenbehandlung an der Wirbels\u00e4ule?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-31' aria-labelledby='toggle-toggle-id-31' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Meistens sind solche Verfahren innerhalb eines einzigen Tages abgeschlossen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53zfr5-fad6ffc7c8efce8801ff02adce7ee7f3'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-32' data-fake-id='#toggle-id-32' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-32' data-slide-speed=\"200\" data-title=\"Darf ich nach der Behandlung Auto fahren?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Darf ich nach der Behandlung Auto fahren?\" data-aria_expanded=\"Click to collapse: Darf ich nach der Behandlung Auto fahren?\">Darf ich nach der Behandlung Auto fahren?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-32' aria-labelledby='toggle-toggle-id-32' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Bei den meisten Verfahren wird eine Lokalan\u00e4sthesie verwendet.<br \/>\nAufgrund des nicht-chirurgischen Charakters der Verfahren sind die Patienten nicht hospitalisiert und k\u00f6nnen direkt nach dem Eingriff gehen. Trotzdem werden sie streng angewiesen, sich <strong>nicht<\/strong> am F\u00fchren eines Fahrzeugs zu beteiligen.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53z2pd-875e1f81af8252275079f03450283e4c'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-33' data-fake-id='#toggle-id-33' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-33' data-slide-speed=\"200\" data-title=\"Bekomme ich nach der Behandlung einen Rehaplan und worauf muss ich achten?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Bekomme ich nach der Behandlung einen Rehaplan und worauf muss ich achten?\" data-aria_expanded=\"Click to collapse: Bekomme ich nach der Behandlung einen Rehaplan und worauf muss ich achten?\">Bekomme ich nach der Behandlung einen Rehaplan und worauf muss ich achten?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-33' aria-labelledby='toggle-toggle-id-33' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Jeder Patient erh\u00e4lt einen individuellen Rehabilitationsplan. Sie werden \u00fcber die Art von Schmerzmitteln beraten, die Sie einnehmen d\u00fcrfen, wenn Sie in den ersten N\u00e4chten nach dem Eingriff Schmerzen versp\u00fcren.<br \/>\nSie werden angewiesen, nach dem Eingriff 24 Stunden lang nicht zu duschen. Sie werden auch aufgefordert, Ihre Mobilit\u00e4t f\u00fcr 24 Stunden nach dem Eingriff zu reduzieren.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53ysjq-8b1035c2ab3675f1623696a0aef0ae32'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-34' data-fake-id='#toggle-id-34' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-34' data-slide-speed=\"200\" data-title=\"Hift mir ein Infrarot-Heizkissen?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Hift mir ein Infrarot-Heizkissen?\" data-aria_expanded=\"Click to collapse: Hift mir ein Infrarot-Heizkissen?\">Hift mir ein Infrarot-Heizkissen?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-34' aria-labelledby='toggle-toggle-id-34' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Ja! Infrarot-Heizkissen \u00a0lindern nicht nur den Schmerz, sondern aktivieren auch den Stoffwechsel der Stammzellen. Bitte bringen Sie zur Prozedur Ihre eigene Infrarotmatte, Sie werden sie unmittelbar nach der Prozedur brauchen.<\/p>\n<p>Bestellen k\u00f6nnen Sie hier:<\/p>\n<p>www.utktechnology.com\/product\/utk-far-infrared-back-natural-jade-heating-pad-small-pro-size.html?mc=24640mw8qAGR4Ihn<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53tokl-7da0aeae2b1464523ebab273dfa7fd50'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-35' data-fake-id='#toggle-id-35' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-35' data-slide-speed=\"200\" data-title=\"Ich bin ein H\u00fcft- oder Wirbels\u00e4ulen-Patient, Hilft mir die R\u00fcckenstreckbank (inversion table)?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Ich bin ein H\u00fcft- oder Wirbels\u00e4ulen-Patient, Hilft mir die R\u00fcckenstreckbank (inversion table)?\" data-aria_expanded=\"Click to collapse: Ich bin ein H\u00fcft- oder Wirbels\u00e4ulen-Patient, Hilft mir die R\u00fcckenstreckbank (inversion table)?\">Ich bin ein H\u00fcft- oder Wirbels\u00e4ulen-Patient, Hilft mir die R\u00fcckenstreckbank (inversion table)?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-35' aria-labelledby='toggle-toggle-id-35' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>In den meisten F\u00e4llen \u2013 ja. Bitte beachten Sie, dass dieses Verfahren beispielsweise nicht f\u00fcr Patienten geeignet ist, die einen H\u00fcftgelenkersatz haben. Bitte fragen Sie uns nach weiteren Details.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2mb008-8394e8f40f649ae1ce495c67b8f31bb1'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-36' data-fake-id='#toggle-id-36' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-36' data-slide-speed=\"200\" data-title=\"Wie komme ich zur OREME-Klinik?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Wie komme ich zur OREME-Klinik?\" data-aria_expanded=\"Click to collapse: Wie komme ich zur OREME-Klinik?\">Wie komme ich zur OREME-Klinik?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-36' aria-labelledby='toggle-toggle-id-36' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Unsere Adresse:<\/p>\n<p>Hauptstrasse 2<br \/>\nCH-9053 Teufen<br \/>\nSchweiz<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2mc1c4-de961b2463a8c74326e9a13c7955e7ad'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-37' data-fake-id='#toggle-id-37' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-37' data-slide-speed=\"200\" data-title=\"Taxi?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Taxi?\" data-aria_expanded=\"Click to collapse: Taxi?\">Taxi?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-37' aria-labelledby='toggle-toggle-id-37' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Taxi oder \u00f6ffentliche Verkehrsmittel sind in der Schweiz weit verbreitet.<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-lp2mdwsk-60fad057d1315a16b0fefe5d89dc62ce'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-38' data-fake-id='#toggle-id-38' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-38' data-slide-speed=\"200\" data-title=\"\u00d6ffentlicher Nahverkehr?\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: \u00d6ffentlicher Nahverkehr?\" data-aria_expanded=\"Click to collapse: \u00d6ffentlicher Nahverkehr?\">\u00d6ffentlicher Nahverkehr?<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-38' aria-labelledby='toggle-toggle-id-38' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Bahn- und Bushaltestelle: &#8222;Teufen AR Bahnhof&#8220; ca. 9 min zu Fuss bis zur der Praxis<\/p>\n<\/div><\/div><\/div><\/section>\n<section class='av_toggle_section av-mn53paec-988097e9192fd269f644c5d8d48f7bcc'  itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div role=\"tablist\" class=\"single_toggle\" data-tags=\"{Alle} \"  ><p id='toggle-toggle-id-39' data-fake-id='#toggle-id-39' class='toggler  av-title-above '  itemprop=\"headline\"  role='tab' tabindex='0' aria-controls='toggle-id-39' data-slide-speed=\"200\" data-title=\"Hotels und B&amp;B\" data-title-open=\"\" data-aria_collapsed=\"Click to expand: Hotels und B&amp;B\" data-aria_expanded=\"Click to collapse: Hotels und B&amp;B\">Hotels und B&amp;B<span class=\"toggle_icon\"><span class=\"vert_icon\"><\/span><span class=\"hor_icon\"><\/span><\/span><\/p><div id='toggle-id-39' aria-labelledby='toggle-toggle-id-39' role='region' class='toggle_wrap  av-title-above'  ><div class='toggle_content invers-color '  itemprop=\"text\" ><p>Wir verkaufen keine Behandlungen mit Hotelpaketen. Wir besch\u00e4ftigen uns ausschlie\u00dflich mit medizinischen \u00a0Behandlungen der Patienten.<br \/>\nSollten Sie jedoch ein Hotel oder ein B &amp; B suchen, z\u00f6gern Sie nicht, uns zu fragen oder besuchen Sie eine Hotelbuchungswebseite f\u00fcr Hotels in der N\u00e4he der Klinik.<\/p>\n<\/div><\/div><\/div><\/section>\n<\/div><\/p><\/div>\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_one_full-15d750bd1b332b34c6e70b077ebbccdf\">\n.flex_column.av-av_one_full-15d750bd1b332b34c6e70b077ebbccdf{\nborder-radius:0px 0px 0px 0px;\npadding:0px 0px 0px 0px;\n}\n<\/style>\n<div  class='flex_column av-av_one_full-15d750bd1b332b34c6e70b077ebbccdf av_one_full  avia-builder-el-4  el_after_av_one_full  avia-builder-el-last  first flex_column_div av-zero-column-padding  column-top-margin'     ><section  class='av_textblock_section av-av_textblock-2de302bf1aa3cf4c9157dbe6f50ac7eb '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p>Gerne stehen wir f\u00fcr weitere Fragen zur Verf\u00fcgung!<\/p>\n<\/div><\/section><\/div><\/div><\/div><\/main><!-- close content main element --><\/div><\/div><\/div><div id='after_section_1'  class='main_color av_default_container_wrap container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><div class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-1781'><div class='entry-content-wrapper clearfix'>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":24,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1781","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>FAQ &#8211; oreme - Nichtinvasive orthop\u00e4dische regenerative Medizin der n\u00e4chsten Generation in Europa<\/title>\n<meta name=\"description\" content=\"Orthop\u00e4dische regenerative Medizin der n\u00e4chsten Generation. 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