{"id":2249,"date":"2023-11-14T11:27:44","date_gmt":"2023-11-14T16:27:44","guid":{"rendered":"https:\/\/orthodontistetellier.mlbwdev.com\/questionnaire-medical\/"},"modified":"2024-04-11T10:21:39","modified_gmt":"2024-04-11T14:21:39","slug":"health-and-dental-questionnaire","status":"publish","type":"page","link":"https:\/\/orthodontiecdn.com\/en\/health-and-dental-questionnaire\/","title":{"rendered":"HEALTH AND DENTAL QUESTIONNAIRE"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2249\" class=\"elementor elementor-2249 elementor-2197\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f0b8ee8 elementor-section-content-middle pv100 ph elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f0b8ee8\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f286b56\" data-id=\"f286b56\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3799e31 elementor-widget elementor-widget-heading\" data-id=\"3799e31\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">CONFIDENTIAL HEALTH AND DENTAL QUESTIONNAIRE<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0d10800 elementor-widget elementor-widget-text-editor\" data-id=\"0d10800\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"text-align: center;\">Please complete the online form below or download the PDF version of the questionnaire.<br>You can download the questionnaire <a href=\"https:\/\/orthodontiecdn.com\/en\/about\/book-first-appointment\/\">here<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0d44366 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"0d44366\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/orthodontiecdn.com\/wp-content\/uploads\/2023\/11\/CONFIDENTIAL-HEALTH-AND-DENTAL-QUESTIONNAIRE.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-download\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">HEALTH AND DENTAL QUESTIONNAIRE<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-861f0c2 ph pv50 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"861f0c2\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-21b109b\" data-id=\"21b109b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3181269 medical-form elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"3181269\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"jupiterx-widget widget_gform_widget\"><div class=\"jupiterx-widget-content\"><script id=\"wp-dom-ready-js\" src=\"https:\/\/orthodontiecdn.com\/wp-includes\/js\/dist\/dom-ready.min.js?ver=a06281ae5cf5500e9317\"><\/script>\n<script id=\"wp-hooks-js\" src=\"https:\/\/orthodontiecdn.com\/wp-includes\/js\/dist\/hooks.min.js?ver=7496969728ca0f95732d\"><\/script>\n<script id=\"wp-i18n-js\" src=\"https:\/\/orthodontiecdn.com\/wp-includes\/js\/dist\/i18n.min.js?ver=781d11515ad3d91786ec\"><\/script>\n<script id=\"wp-i18n-js-after\">\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/\/# sourceURL=wp-i18n-js-after\n<\/script>\n<script id=\"wp-a11y-js-translations\">\n( function( domain, translations ) {\n\tvar localeData = translations.locale_data[ domain ] || translations.locale_data.messages;\n\tlocaleData[\"\"].domain = domain;\n\twp.i18n.setLocaleData( localeData, domain );\n} )( \"default\", {\"translation-revision-date\":\"2024-07-13 10:48:39+0000\",\"generator\":\"GlotPress\\\/4.0.1\",\"domain\":\"messages\",\"locale_data\":{\"messages\":{\"\":{\"domain\":\"messages\",\"plural-forms\":\"nplurals=2; plural=n != 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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<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/en\/wp-json\/wp\/v2\/pages\/2249#gf_8' data-formid='8' novalidate>\n        <div id='gf_progressbar_wrapper_8' class='gf_progressbar_wrapper' data-start-at-zero='1'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_0' style='width:0%; color:; background-color:#2D384A;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_8_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_8_22\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><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_8_22'>\n                            \n                            <span id='input_8_22_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.3' id='input_8_22_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_22_3' class='gform-field-label gform-field-label--type-sub '>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_22_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_22.6' id='input_8_22_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_22_6' class='gform-field-label gform-field-label--type-sub '>Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_8_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half sexe gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_4'>\n\t\t\t<div class='gchoice gchoice_8_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='H'  id='choice_8_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_4_0' id='label_8_4_0' class='gform-field-label gform-field-label--type-inline'>H<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='F' checked='checked' id='choice_8_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_4_1' id='label_8_4_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full adresse gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_8_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_8_23_1' value=''    aria-required='true'    \/>\n                                        <label for='input_8_23_1' id='input_8_23_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_8_23_3' value=''    aria-required='true'    \/>\n                                    <label for='input_8_23_3' id='input_8_23_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_8_23_4_container' >\n                                        <input type='text' name='input_23.4' id='input_8_23_4' value=''      aria-required='true'    \/>\n                                        <label for='input_8_23_4' id='input_8_23_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_8_23_5_container' >\n                                    <input type='text' name='input_23.5' id='input_8_23_5' value=''    aria-required='true'    \/>\n                                    <label for='input_8_23_5' id='input_8_23_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_8_23_6_container' >\n                                        <select name='input_23.6' id='input_8_23_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' selected='selected'>Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/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='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/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='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/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='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/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='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/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='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/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 Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/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='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/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 and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/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='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_8_23_6' id='input_8_23_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_25'>Work phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_8_25' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_25\"  \/><\/div><div class='gfield_description' id='gfield_description_8_25'>Work phone<\/div><\/div><div id=\"field_8_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_24'>Home phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_8_24' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_24\"  \/><\/div><div class='gfield_description' id='gfield_description_8_24'>Home phone<\/div><\/div><div id=\"field_8_26\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_26'>Ext.<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_8_26' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_26\"  \/><\/div><div class='gfield_description' id='gfield_description_8_26'>Ext.<\/div><\/div><div id=\"field_8_169\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_169'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_169' id='input_8_169' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_169\"  \/><\/div><div class='gfield_description' id='gfield_description_8_169'>Cell Phone<\/div><\/div><div id=\"field_8_27\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full 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 screen-reader-text' for='input_8_27'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_27' id='input_8_27' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_8_27\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_8_27'>Email<\/div><\/div><div id=\"field_8_28\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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 screen-reader-text' for='input_8_28'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_8_28' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_8_28_date_format gfield_description_8_28\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_28_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_28' class='gform_hidden' value='https:\/\/orthodontiecdn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_8_28'>Date of birth <\/div><\/div><div id=\"field_8_17\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half 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 screen-reader-text' for='input_8_17'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_8_17' type='number' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_8_17\" \/><\/div><div class='gfield_description' id='gfield_description_8_17'>Age<\/div><\/div><div id=\"field_8_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_18'>Who may we thank for referring you to our office?<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_8_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_18\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_8_18'>Who may we thank for referring you to our office?<\/div><\/div><div id=\"field_8_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_19'>Name of your dentist:<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_8_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_19\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_8_19'>Name of your dentist:<\/div><\/div><div id=\"field_8_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_20'>Object of the consultation:<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_8_20' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_20\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_8_20'>Object of the consultation:<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_8_164' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_2' class='gform_page' data-js='page-field-id-164' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection section-formulaire field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PARENT(S) INFORMATION (IF UNDER 18 YEARS OLD)<\/h3><\/div><fieldset id=\"field_8_30\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><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_8_30'>\n                            \n                            <span id='input_8_30_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.3' id='input_8_30_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_30_3' class='gform-field-label gform-field-label--type-sub '>Mother\u2019s first name:<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_30_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.6' id='input_8_30_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_30_6' class='gform-field-label gform-field-label--type-sub '>Mother\u2019s last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_31\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_31'>Cell phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_8_31' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_31\"  \/><\/div><div class='gfield_description' id='gfield_description_8_31'>Cell phone<\/div><\/div><div id=\"field_8_32\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_32'>Work phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_8_32' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_32\"  \/><\/div><div class='gfield_description' id='gfield_description_8_32'>Work phone:<\/div><\/div><div id=\"field_8_33\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_33'>ext.<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_8_33' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_33\"  \/><\/div><div class='gfield_description' id='gfield_description_8_33'>ext.<\/div><\/div><div id=\"field_8_34\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_34'>email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_8_34' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_8_34\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_8_34'>email<\/div><\/div><fieldset id=\"field_8_35\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><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_8_35'>\n                            \n                            <span id='input_8_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_8_35_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_35_3' class='gform-field-label gform-field-label--type-sub '>Father\u2019s first name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_8_35_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_8_35_6' class='gform-field-label gform-field-label--type-sub '>Father\u2019s last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_36'>Cell phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_8_36' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_36\"  \/><\/div><div class='gfield_description' id='gfield_description_8_36'>Cell phone<\/div><\/div><div id=\"field_8_37\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_37'>Work phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_8_37' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_37\"  \/><\/div><div class='gfield_description' id='gfield_description_8_37'>Work phone<\/div><\/div><div id=\"field_8_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_38'>ext.<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_8_38' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_38\"  \/><\/div><div class='gfield_description' id='gfield_description_8_38'>ext.<\/div><\/div><div id=\"field_8_39\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_39'>email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_39' id='input_8_39' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_8_39\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_8_39'>email<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_165' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_8_165' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_3' class='gform_page' data-js='page-field-id-165' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection section-formulaire field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_8_42'>DENTAL HISTORY\n<\/div><\/div><fieldset id=\"field_8_120\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Last dental visit<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_120'>\n\t\t\t<div class='gchoice gchoice_8_120_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='0-6 months'  id='choice_8_120_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_120_0' id='label_8_120_0' class='gform-field-label gform-field-label--type-inline'>0-6 months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_120_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='6-12 months'  id='choice_8_120_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_120_1' id='label_8_120_1' class='gform-field-label gform-field-label--type-inline'>6-12 months<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_120_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_120' type='radio' value='more than de 12 months'  id='choice_8_120_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_120_2' id='label_8_120_2' class='gform-field-label gform-field-label--type-inline'>more than de 12 months<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_44'>2. Treatment received at that the last visit:<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_8_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_166' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_8_166' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_4' class='gform_page' data-js='page-field-id-166' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_45\" class=\"gfield gfield--type-section gfield--input-type-section gsection section-formulaire field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MEDICAL HISTORY<\/h3><\/div><div id=\"field_8_46\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_46'>1. Are you actually under the care of a physician (or specialist, cardiologist, etc.)?<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_8_46' class='large gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_8_49\" 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\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_8_49'>If yes, please provide us with the following information:<\/div><\/div><fieldset id=\"field_8_50\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_8_50'>\n                            \n                            \n                            \n                            <span id='input_8_50_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_50.6' id='input_8_50_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_50_6' class='gform-field-label gform-field-label--type-sub '>Name of physician<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_51\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_8_51'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_51' id='input_8_51' type='tel' value='' class='medium'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_51\"  \/><\/div><div class='gfield_description' id='gfield_description_8_51'>Phone<\/div><\/div><fieldset id=\"field_8_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Do you take any medication or did you take any during the last 6 months?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_121'>\n\t\t\t<div class='gchoice gchoice_8_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Yes'  id='choice_8_121_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_121_0' id='label_8_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='No'  id='choice_8_121_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_121_1' id='label_8_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_54'>If yes, please write the name and dosage of the medication(s):<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_8_54' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_122\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Have you lost or gained a lot of weight recently?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_122'>\n\t\t\t<div class='gchoice gchoice_8_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Yes'  id='choice_8_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_122_0' id='label_8_122_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='No'  id='choice_8_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_122_1' id='label_8_122_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. If you are a woman, are you pregnant?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_123'>\n\t\t\t<div class='gchoice gchoice_8_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Yes'  id='choice_8_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_123_0' id='label_8_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='No'  id='choice_8_123_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_123_1' id='label_8_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_124\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. If you are a woman, do you take contraceptive medication?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_124'>\n\t\t\t<div class='gchoice gchoice_8_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Yes'  id='choice_8_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_124_0' id='label_8_124_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='No'  id='choice_8_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_124_1' id='label_8_124_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_167' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_8_167' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_5' class='gform_page' data-js='page-field-id-167' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection section-formulaire field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DO YOU HAVE OR HAD THE FOLLOWING MEDICAL CONDITION:<\/h3><\/div><fieldset id=\"field_8_125\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Heart related problems (stroke, heart attack, angina, valvular problems, etc.)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_125'>\n\t\t\t<div class='gchoice gchoice_8_125_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='Yes'  id='choice_8_125_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_125_0' id='label_8_125_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_125_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_125' type='radio' value='No'  id='choice_8_125_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_125_1' id='label_8_125_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_126\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Rheumatic fever<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_126'>\n\t\t\t<div class='gchoice gchoice_8_126_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='Yes'  id='choice_8_126_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_126_0' id='label_8_126_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_126_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_126' type='radio' value='No'  id='choice_8_126_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_126_1' id='label_8_126_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_127\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Blood disorders (prolonged bleeding, hemophilia)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_127'>\n\t\t\t<div class='gchoice gchoice_8_127_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='Yes'  id='choice_8_127_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_127_0' id='label_8_127_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_127_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_127' type='radio' value='No'  id='choice_8_127_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_127_1' id='label_8_127_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Anemia<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_129'>\n\t\t\t<div class='gchoice gchoice_8_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Yes'  id='choice_8_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_129_0' id='label_8_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No'  id='choice_8_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_129_1' id='label_8_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >10. Blood pressure<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_128'>\n\t\t\t<div class='gchoice gchoice_8_128_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='High'  id='choice_8_128_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_128_0' id='label_8_128_0' class='gform-field-label gform-field-label--type-inline'>High<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_128_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Low'  id='choice_8_128_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_128_1' id='label_8_128_1' class='gform-field-label gform-field-label--type-inline'>Low<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_128_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_128' type='radio' value='Normal'  id='choice_8_128_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_128_2' id='label_8_128_2' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >11. Frequent colds or sinusitis<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_130'>\n\t\t\t<div class='gchoice gchoice_8_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Yes'  id='choice_8_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_130_0' id='label_8_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_8_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_130_1' id='label_8_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >12. Tuberculosis or pulmonary disease<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_131'>\n\t\t\t<div class='gchoice gchoice_8_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Yes'  id='choice_8_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_131_0' id='label_8_131_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='No'  id='choice_8_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_131_1' id='label_8_131_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_132\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >13. Digestive disorders<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_132'>\n\t\t\t<div class='gchoice gchoice_8_132_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='Yes'  id='choice_8_132_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_132_0' id='label_8_132_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_132_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_132' type='radio' value='No'  id='choice_8_132_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_132_1' id='label_8_132_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >14. Stomach ulcers<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_133'>\n\t\t\t<div class='gchoice gchoice_8_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Yes'  id='choice_8_133_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_133_0' id='label_8_133_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='No'  id='choice_8_133_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_133_1' id='label_8_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >15. Liver disorders (hepatitis virus A,B,C, cirrhosis, etc.)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_134'>\n\t\t\t<div class='gchoice gchoice_8_134_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='Yes'  id='choice_8_134_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_134_0' id='label_8_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_134_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_134' type='radio' value='No'  id='choice_8_134_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_134_1' id='label_8_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >16. Renal disease<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_135'>\n\t\t\t<div class='gchoice gchoice_8_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Yes'  id='choice_8_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_135_0' id='label_8_135_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='No'  id='choice_8_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_135_1' id='label_8_135_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >17. Sexually transmitted infection (STI)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_136'>\n\t\t\t<div class='gchoice gchoice_8_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_8_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_136_0' id='label_8_136_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_8_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_136_1' id='label_8_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >18. Diabetes<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_137'>\n\t\t\t<div class='gchoice gchoice_8_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Yes'  id='choice_8_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_137_0' id='label_8_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='No'  id='choice_8_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_137_1' id='label_8_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_138\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >19. Thyroid disorde<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_138'>\n\t\t\t<div class='gchoice gchoice_8_138_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='Yes'  id='choice_8_138_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_138_0' id='label_8_138_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_138_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_138' type='radio' value='No'  id='choice_8_138_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_138_1' id='label_8_138_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >20. Skin diseases<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_139'>\n\t\t\t<div class='gchoice gchoice_8_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Yes'  id='choice_8_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_139_0' id='label_8_139_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='No'  id='choice_8_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_139_1' id='label_8_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >21. Eye problems<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_140'>\n\t\t\t<div class='gchoice gchoice_8_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Yes'  id='choice_8_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_140_0' id='label_8_140_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='No'  id='choice_8_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_140_1' id='label_8_140_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >22. Arthritis<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_141'>\n\t\t\t<div class='gchoice gchoice_8_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_8_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_141_0' id='label_8_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_8_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_141_1' id='label_8_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >23. Epilepsy<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_142'>\n\t\t\t<div class='gchoice gchoice_8_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_8_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_142_0' id='label_8_142_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_8_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_142_1' id='label_8_142_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_143\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >24. Nervous disorders<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_143'>\n\t\t\t<div class='gchoice gchoice_8_143_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='Yes'  id='choice_8_143_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_143_0' id='label_8_143_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_143_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_143' type='radio' value='No'  id='choice_8_143_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_143_1' id='label_8_143_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >25. Frequent headaches<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_144'>\n\t\t\t<div class='gchoice gchoice_8_144_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='Yes'  id='choice_8_144_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_144_0' id='label_8_144_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_144_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='No'  id='choice_8_144_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_144_1' id='label_8_144_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >26. Dizziness or fainting<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_145'>\n\t\t\t<div class='gchoice gchoice_8_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Yes'  id='choice_8_145_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_145_0' id='label_8_145_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='No'  id='choice_8_145_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_145_1' id='label_8_145_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >27. Ear aches<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_146'>\n\t\t\t<div class='gchoice gchoice_8_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_8_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_146_0' id='label_8_146_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_8_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_146_1' id='label_8_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >28. Hay fever (seasonal allergies)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_147'>\n\t\t\t<div class='gchoice gchoice_8_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='Yes'  id='choice_8_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_147_0' id='label_8_147_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='No'  id='choice_8_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_147_1' id='label_8_147_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >29. Asthma<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_148'>\n\t\t\t<div class='gchoice gchoice_8_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Yes'  id='choice_8_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_148_0' id='label_8_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='No'  id='choice_8_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_148_1' id='label_8_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >30. Do you smoke?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_149'>\n\t\t\t<div class='gchoice gchoice_8_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Yes'  id='choice_8_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_149_0' id='label_8_149_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='No'  id='choice_8_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_149_1' id='label_8_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_85'>If yes, how many cigarettes per day?<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_8_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_86'>For how many years?<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_8_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_150\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >31. Have you ever had radiotherapy and\/or chemotherapy for a cancer?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_150'>\n\t\t\t<div class='gchoice gchoice_8_150_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Yes'  id='choice_8_150_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_150_0' id='label_8_150_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_150_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='No'  id='choice_8_150_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_150_1' id='label_8_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_88'>If yes, which type of cancer?<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_8_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_151\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >32. Have you been given the diagnosis of AIDS?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_151'>\n\t\t\t<div class='gchoice gchoice_8_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='Yes'  id='choice_8_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_151_0' id='label_8_151_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='No'  id='choice_8_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_151_1' id='label_8_151_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_152\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >33. Are you HIV positive?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_152'>\n\t\t\t<div class='gchoice gchoice_8_152_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='Yes'  id='choice_8_152_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_152_0' id='label_8_152_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_152_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_152' type='radio' value='No'  id='choice_8_152_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_152_1' id='label_8_152_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >34. Do you have any prosthetic devices (knee or hip)?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_153'>\n\t\t\t<div class='gchoice gchoice_8_153_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='Yes'  id='choice_8_153_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_153_0' id='label_8_153_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_153_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='No'  id='choice_8_153_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_153_1' id='label_8_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >35. Is it recommended by your physician to take antibiotics before a visit at your dentist?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_154'>\n\t\t\t<div class='gchoice gchoice_8_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Yes'  id='choice_8_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_154_0' id='label_8_154_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='No'  id='choice_8_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_154_1' id='label_8_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_93\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >36. Are you allergic or have you had any adverse reaction to the following products?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_93'><div class='gchoice gchoice_8_93_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.1' type='checkbox'  value='Latex'  id='choice_8_93_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_1' id='label_8_93_1' class='gform-field-label gform-field-label--type-inline'>Latex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.2' type='checkbox'  value='Penicillin'  id='choice_8_93_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_2' id='label_8_93_2' class='gform-field-label gform-field-label--type-inline'>Penicillin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.3' type='checkbox'  value='Aspirin'  id='choice_8_93_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_3' id='label_8_93_3' class='gform-field-label gform-field-label--type-inline'>Aspirin<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.4' type='checkbox'  value='Codeine'  id='choice_8_93_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_4' id='label_8_93_4' class='gform-field-label gform-field-label--type-inline'>Codeine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.5' type='checkbox'  value='Local anesthetics'  id='choice_8_93_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_5' id='label_8_93_5' class='gform-field-label gform-field-label--type-inline'>Local anesthetics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.6' type='checkbox'  value='Food'  id='choice_8_93_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_6' id='label_8_93_6' class='gform-field-label gform-field-label--type-inline'>Food<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.7' type='checkbox'  value='Iodine'  id='choice_8_93_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_7' id='label_8_93_7' class='gform-field-label gform-field-label--type-inline'>Iodine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.8' type='checkbox'  value='Sulfas'  id='choice_8_93_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_8' id='label_8_93_8' class='gform-field-label gform-field-label--type-inline'>Sulfas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.9' type='checkbox'  value='Nickel'  id='choice_8_93_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_9' id='label_8_93_9' class='gform-field-label gform-field-label--type-inline'>Nickel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.11' type='checkbox'  value='Copper and other metals'  id='choice_8_93_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_11' id='label_8_93_11' class='gform-field-label gform-field-label--type-inline'>Copper and other metals<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_93_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.12' type='checkbox'  value='Others'  id='choice_8_93_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_93_12' id='label_8_93_12' class='gform-field-label gform-field-label--type-inline'>Others<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_94\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_94'>Specify<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_8_94' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >38. Have you ever been hospitalized and\/or had surgery for any health problem other than dental?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_155'>\n\t\t\t<div class='gchoice gchoice_8_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Yes'  id='choice_8_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_155_0' id='label_8_155_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='No'  id='choice_8_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_155_1' id='label_8_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_118'>If yes, when and explain :<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_8_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_97'>38. Please, inform us of any other medical problem not mentioned above<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_8_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_168' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_8_168' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_6' class='gform_page' data-js='page-field-id-168' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_98\" class=\"gfield gfield--type-section gfield--input-type-section gsection section-formulaire field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ORTHODONTIC QUESTIONNAIRE<\/h3><\/div><fieldset id=\"field_8_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Have you ever suffered from a dental, facial or head trauma\/accident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_156'>\n\t\t\t<div class='gchoice gchoice_8_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='Yes'  id='choice_8_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_156_0' id='label_8_156_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='No'  id='choice_8_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_156_1' id='label_8_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_100'>If yes, what kind of trauma<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_8_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Do you grind your teeth at night?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_157'>\n\t\t\t<div class='gchoice gchoice_8_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Yes'  id='choice_8_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_157_0' id='label_8_157_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='No'  id='choice_8_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_157_1' id='label_8_157_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Do you have pain, clicking or any symptoms to the jaw\/joint?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_158'>\n\t\t\t<div class='gchoice gchoice_8_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_8_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_158_0' id='label_8_158_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_8_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_158_1' id='label_8_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_103'>If yes, please describe<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_8_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you ever had any previous orthodontic treatment?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_159'>\n\t\t\t<div class='gchoice gchoice_8_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='Yes'  id='choice_8_159_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_159_0' id='label_8_159_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_159_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='No'  id='choice_8_159_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_159_1' id='label_8_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_105'>If yes, when and what kind of treatment:<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_8_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_160\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you ever sucked your thumb\/fnger?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_160'>\n\t\t\t<div class='gchoice gchoice_8_160_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='Yes'  id='choice_8_160_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_160_0' id='label_8_160_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_160_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='Yes and still have the habit'  id='choice_8_160_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_160_1' id='label_8_160_1' class='gform-field-label gform-field-label--type-inline'>Yes and still have the habit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_160_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='No'  id='choice_8_160_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_160_2' id='label_8_160_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Do you have tongue or speech problems?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_161'>\n\t\t\t<div class='gchoice gchoice_8_161_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='Yes'  id='choice_8_161_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_161_0' id='label_8_161_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_161_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='No'  id='choice_8_161_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_161_1' id='label_8_161_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_108\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_108'>If yes, please describe:<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_8_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_162\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Do you breathe through\u2026?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_162'>\n\t\t\t<div class='gchoice gchoice_8_162_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='The mouth'  id='choice_8_162_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_162_0' id='label_8_162_0' class='gform-field-label gform-field-label--type-inline'>The mouth<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_162_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='The nose'  id='choice_8_162_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_162_1' id='label_8_162_1' class='gform-field-label gform-field-label--type-inline'>The nose<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_162_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='Both'  id='choice_8_162_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_162_2' id='label_8_162_2' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. Do you bite your nails?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_163'>\n\t\t\t<div class='gchoice gchoice_8_163_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='Yes'  id='choice_8_163_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_163_0' id='label_8_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_163_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_163' type='radio' value='No'  id='choice_8_163_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_163_1' id='label_8_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_111\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full notes-supplementaires 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 screen-reader-text' for='input_8_111'>I, undersigned, certify that I have read, understood, asked the necessary questions and answered this medical and\ndental questionnaire to the best of my knowledge. I will inform my dentist of any changes affecting my health. I\nauthorize the opening of my record at this offce and its follow-up.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_111' id='input_8_111' class='textarea small'  aria-describedby=\"gfield_description_8_111\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_8_111'>I, undersigned, certify that I have read, understood, asked the necessary questions and answered this medical and\ndental questionnaire to the best of my knowledge. I will inform my dentist of any changes affecting my health. I\nauthorize the opening of my record at this offce and its follow-up.<\/div><\/div><div id=\"field_8_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half zone-signature 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 screen-reader-text' for='input_8_112'>Patient signature or parent (if under 18 years old)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_8_112' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_112\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_8_112'>Patient signature or parent (if under 18 years old)<\/div><\/div><div id=\"field_8_113\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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 screen-reader-text' for='input_8_113'>Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_113' id='input_8_113' type='text' value='' class='datepicker gform-datepicker ymd_slash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy\/mm\/dd' aria-describedby=\"input_8_113_date_format gfield_description_8_113\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_113_date_format' class='screen-reader-text'>YYYY slash MM slash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_113' class='gform_hidden' value='https:\/\/orthodontiecdn.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_8_113'>Date<\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_8' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='submit' id='gform_submit_button_8' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=8&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;hash=485d9373b54265781f024b514d9358d9' \/>\n         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name='state_8' 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