{"id":396,"date":"2018-02-02T11:44:27","date_gmt":"2018-02-02T17:44:27","guid":{"rendered":"http:\/\/fawstudio-dev.site\/2017\/dreduardo\/?page_id=396"},"modified":"2018-03-07T18:10:37","modified_gmt":"2018-03-08T00:10:37","slug":"questionnaire-ingles","status":"publish","type":"page","link":"https:\/\/dreduardo.com.mx\/en\/questionnaire-ingles\/","title":{"rendered":"Questionnaire ingles"},"content":{"rendered":"[mk_page_section bg_image=&#8221;http:\/\/dreduardo.com.mx\/wp-content\/uploads\/2017\/11\/bg_nosotros.jpg&#8221; bg_position=&#8221;center center&#8221; bg_repeat=&#8221;no-repeat&#8221; bg_stretch=&#8221;true&#8221; min_height=&#8221;300&#8243; sidebar=&#8221;sidebar-1&#8243;][vc_column][mk_fancy_title color=&#8221;#ffffff&#8221; size=&#8221;40&#8243; font_weight=&#8221;300&#8243; margin_top=&#8221;100&#8243; font_family=&#8221;Open+Sans&#8221; font_type=&#8221;google&#8221; align=&#8221;center&#8221;]\n<p class=\"p1\"><span class=\"s1\">Questionnaire<\/span><\/p>\n[\/mk_fancy_title][vc_column_text css=&#8221;.vc_custom_1517593651558{margin-bottom: 0px !important;}&#8221;]The purpose of this questionnaire is to have specific information about your clinical history and thus be able to asses your current health status. This information is vital for us because it gives us the opportunity to formulate a unique preoperative preparation in order to offer you the best and safest weight reducing surgical procedure, so try to answer it as thourough as posible.[\/vc_column_text][\/vc_column][\/mk_page_section][mk_page_section bg_color=&#8221;#f3f9f9&#8243; sidebar=&#8221;sidebar-1&#8243;][vc_column][vc_row_inner is_fullwidth_content=&#8221;false&#8221;][vc_column_inner]\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_2' style='display:none'><a id='gf_2' class='gform_anchor' ><\/a><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/396#gf_2'>\n                        <div class='gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_2_20' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Contact information<\/h3><\/li><li id='field_2_10' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_10' >Name<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='medium'  tabindex='1'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_3' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_3' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_2_3' type='text' value='' class='medium' tabindex='2'     aria-invalid=\"false\"\/>\n                        <\/div><\/li><li id='field_2_4' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_4' >Mobile phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='text' value='' class='medium' tabindex='3'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_5' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_5' >Home phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='text' value='' class='medium' tabindex='4'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_7' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_7' >Work phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='text' value='' class='medium' tabindex='5'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_8' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_8' >Best time to call<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'  tabindex='6'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_9' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_9' >Time zone<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='medium'  tabindex='7'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_11' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_11' >City<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='medium'  tabindex='8'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_12' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_12' >State\/province<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'  tabindex='9'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_13' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_13' >Country<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='medium'  tabindex='10'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_14' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_14' >Emergency contact name and phone number<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='medium'  tabindex='11'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_15' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_15' >Guest(s)<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='medium'  tabindex='12'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_21' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Personal information.<\/h3><\/li><li id='field_2_26' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_26' >Name<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_2_26' type='text' value='' class='medium'  tabindex='13'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_23' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_23' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_2_23' type='text'    value='' class='medium' tabindex='14'      aria-invalid=\"false\"\/><\/div><\/li><li id='field_2_25' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gender<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_25'><li class='gchoice_2_25_0'><input name='input_25' type='radio' value='Male'  id='choice_2_25_0' tabindex='15'  onclick='gf_apply_rules(2,[40]);' onkeypress='gf_apply_rules(2,[40]);'  \/><label for='choice_2_25_0' id='label_2_25_0'>Male<\/label><\/li><li class='gchoice_2_25_1'><input name='input_25' type='radio' value='Female'  id='choice_2_25_1' tabindex='16'  onclick='gf_apply_rules(2,[40]);' onkeypress='gf_apply_rules(2,[40]);'  \/><label for='choice_2_25_1' id='label_2_25_1'>Female<\/label><\/li><\/ul><\/div><\/li><li id='field_2_28' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_28' >Weight<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='medium'  tabindex='17'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_29' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_29' >Height<\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_2_29' type='text'    value='' class='medium' tabindex='18'      aria-invalid=\"false\"\/><\/div><\/li><li id='field_2_32' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_32' >Body mass index<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='medium'  tabindex='19'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_33' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_33' >Date of birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_33' id='input_2_33' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='20'  \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_33' class='gform_hidden' value='https:\/\/dreduardo.com.mx\/wp-content\/plugins\/gravityforms%202\/images\/calendar.png'\/><\/li><li id='field_2_34' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_34' >Language spoken<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_2_34' type='text' value='' class='medium'  tabindex='21'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_35' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Family structure.<\/h3><\/li><li id='field_2_36' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_36' >Marital status<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='medium'  tabindex='22'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_37' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_37' >Children<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='medium'  tabindex='23'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_40' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_40' >Pregnancies\/abortions\/births<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='medium'  tabindex='24'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_41' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Occupational information.<\/h3><\/li><li id='field_2_44' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you currently employed\/unemployed?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_44'><li class='gchoice_2_44_0'><input name='input_44' type='radio' value='Employed'  id='choice_2_44_0' tabindex='25'    \/><label for='choice_2_44_0' id='label_2_44_0'>Employed<\/label><\/li><li class='gchoice_2_44_1'><input name='input_44' type='radio' value='Unemployed'  id='choice_2_44_1' tabindex='26'    \/><label for='choice_2_44_1' id='label_2_44_1'>Unemployed<\/label><\/li><\/ul><\/div><\/li><li id='field_2_45' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Is your weight an impediment to perform or find a job?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_45'><li class='gchoice_2_45_0'><input name='input_45' type='radio' value='Yes'  id='choice_2_45_0' tabindex='27'    \/><label for='choice_2_45_0' id='label_2_45_0'>Yes<\/label><\/li><li class='gchoice_2_45_1'><input name='input_45' type='radio' value='No'  id='choice_2_45_1' tabindex='28'    \/><label for='choice_2_45_1' id='label_2_45_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_46' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_46' >What is your occupation?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'  tabindex='29'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_47' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Part time or full time?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_47'><li class='gchoice_2_47_0'><input name='input_47' type='radio' value='Part time'  id='choice_2_47_0' tabindex='30'    \/><label for='choice_2_47_0' id='label_2_47_0'>Part time<\/label><\/li><li class='gchoice_2_47_1'><input name='input_47' type='radio' value='Full time'  id='choice_2_47_1' tabindex='31'    \/><label for='choice_2_47_1' id='label_2_47_1'>Full time<\/label><\/li><\/ul><\/div><\/li><li id='field_2_48' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_48' >What level of activity does your job involve?<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='medium'  tabindex='32'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_49' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Surgery.<\/h3><\/li><li id='field_2_50' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_50' >What type of surgery\/procedure are you interested in?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'  tabindex='33'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_52' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_52' >What is the desired date?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_2_52' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='34'  \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_52' class='gform_hidden' value='https:\/\/dreduardo.com.mx\/wp-content\/plugins\/gravityforms%202\/images\/calendar.png'\/><\/li><li id='field_2_51' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_51' >If not available what other date would you like?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='medium'  tabindex='35'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_53' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you had weight loss surgery before?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_53'><li class='gchoice_2_53_0'><input name='input_53' type='radio' value='Yes'  id='choice_2_53_0' tabindex='36'    \/><label for='choice_2_53_0' id='label_2_53_0'>Yes<\/label><\/li><li class='gchoice_2_53_1'><input name='input_53' type='radio' value='No'  id='choice_2_53_1' tabindex='37'    \/><label for='choice_2_53_1' id='label_2_53_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_54' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_54' >When was it performed?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_2_54' type='text' value='' class='medium'  tabindex='38'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_55' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_55' >What type of procedure was performed?<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='medium'  tabindex='39'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_56' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_56' >Was it open surgery (big incision) or laparoscopic (little incisions)?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='medium'  tabindex='40'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_57' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Drugs and allergies...<\/h3><\/li><li id='field_2_58' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you drink alcohol?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_58'><li class='gchoice_2_58_0'><input name='input_58' type='radio' value='Yes'  id='choice_2_58_0' tabindex='41'    \/><label for='choice_2_58_0' id='label_2_58_0'>Yes<\/label><\/li><li class='gchoice_2_58_1'><input name='input_58' type='radio' value='No'  id='choice_2_58_1' tabindex='42'    \/><label for='choice_2_58_1' id='label_2_58_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_60' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_60' >What type of alcohol do you drink?<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='medium'  tabindex='43'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_59' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you smoke?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'><li class='gchoice_2_59_0'><input name='input_59' type='radio' value='Yes'  id='choice_2_59_0' tabindex='44'  onclick='gf_apply_rules(2,[61,62]);' onkeypress='gf_apply_rules(2,[61,62]);'  \/><label for='choice_2_59_0' id='label_2_59_0'>Yes<\/label><\/li><li class='gchoice_2_59_1'><input name='input_59' type='radio' value='No'  id='choice_2_59_1' tabindex='45'  onclick='gf_apply_rules(2,[61,62]);' onkeypress='gf_apply_rules(2,[61,62]);'  \/><label for='choice_2_59_1' id='label_2_59_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_61' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_61' >How many cigarettes a day?<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_2_61' type='text' value='' class='medium'  tabindex='46'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_62' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_62' >For how long?<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_2_62' type='text' value='' class='medium'  tabindex='47'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_63' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_63' >When did you stop smoking?<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_2_63' type='text' value='' class='medium'  tabindex='48'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_64' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you consume drugs?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_64'><li class='gchoice_2_64_0'><input name='input_64' type='radio' value='Yes'  id='choice_2_64_0' tabindex='49'  onclick='gf_apply_rules(2,[65]);' onkeypress='gf_apply_rules(2,[65]);'  \/><label for='choice_2_64_0' id='label_2_64_0'>Yes<\/label><\/li><li class='gchoice_2_64_1'><input name='input_64' type='radio' value='No'  id='choice_2_64_1' tabindex='50'  onclick='gf_apply_rules(2,[65]);' onkeypress='gf_apply_rules(2,[65]);'  \/><label for='choice_2_64_1' id='label_2_64_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_65' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_65' >What type of drugs do you consume?<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_2_65' type='text' value='' class='medium'  tabindex='51'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_66' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you allergic to medications?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_66'><li class='gchoice_2_66_0'><input name='input_66' type='radio' value='Yes'  id='choice_2_66_0' tabindex='52'  onclick='gf_apply_rules(2,[67,68]);' onkeypress='gf_apply_rules(2,[67,68]);'  \/><label for='choice_2_66_0' id='label_2_66_0'>Yes<\/label><\/li><li class='gchoice_2_66_1'><input name='input_66' type='radio' value='No'  id='choice_2_66_1' tabindex='53'  onclick='gf_apply_rules(2,[67,68]);' onkeypress='gf_apply_rules(2,[67,68]);'  \/><label for='choice_2_66_1' id='label_2_66_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_67' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_67' >Please specify what medications are you allergic to<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='medium'  tabindex='54'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_68' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_68' >Please specify what type of allergy you suffer (skin rash, anaphylaxis, itching, etc)<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='text' value='' class='medium'  tabindex='55'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_69' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you allergic to food?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_69'><li class='gchoice_2_69_0'><input name='input_69' type='radio' value='Yes'  id='choice_2_69_0' tabindex='56'    \/><label for='choice_2_69_0' id='label_2_69_0'>Yes<\/label><\/li><li class='gchoice_2_69_1'><input name='input_69' type='radio' value='No'  id='choice_2_69_1' tabindex='57'    \/><label for='choice_2_69_1' id='label_2_69_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_70' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you allergic to latex?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_70'><li class='gchoice_2_70_0'><input name='input_70' type='radio' value='Yes'  id='choice_2_70_0' tabindex='58'    \/><label for='choice_2_70_0' id='label_2_70_0'>Yes<\/label><\/li><li class='gchoice_2_70_1'><input name='input_70' type='radio' value='No'  id='choice_2_70_1' tabindex='59'    \/><label for='choice_2_70_1' id='label_2_70_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_71' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Sleep apnea symptoms.<\/h3><\/li><li id='field_2_72' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_72' >How many hours do you sleep at night?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_2_72' type='text' value='' class='medium'  tabindex='60'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_73' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you snore?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_73'><li class='gchoice_2_73_0'><input name='input_73' type='radio' value='Yes'  id='choice_2_73_0' tabindex='61'    \/><label for='choice_2_73_0' id='label_2_73_0'>Yes<\/label><\/li><li class='gchoice_2_73_1'><input name='input_73' type='radio' value='No'  id='choice_2_73_1' tabindex='62'    \/><label for='choice_2_73_1' id='label_2_73_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_74' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Has anyone told you, you stop breathing during your sleep?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_74'><li class='gchoice_2_74_0'><input name='input_74' type='radio' value='Yes'  id='choice_2_74_0' tabindex='63'    \/><label for='choice_2_74_0' id='label_2_74_0'>Yes<\/label><\/li><li class='gchoice_2_74_1'><input name='input_74' type='radio' value='No'  id='choice_2_74_1' tabindex='64'    \/><label for='choice_2_74_1' id='label_2_74_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_75' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you feel tired during the day?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_75'><li class='gchoice_2_75_0'><input name='input_75' type='radio' value='Yes'  id='choice_2_75_0' tabindex='65'    \/><label for='choice_2_75_0' id='label_2_75_0'>Yes<\/label><\/li><li class='gchoice_2_75_1'><input name='input_75' type='radio' value='No'  id='choice_2_75_1' tabindex='66'    \/><label for='choice_2_75_1' id='label_2_75_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_76' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you fall asleep at work or during the day?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_76'><li class='gchoice_2_76_0'><input name='input_76' type='radio' value='Yes'  id='choice_2_76_0' tabindex='67'    \/><label for='choice_2_76_0' id='label_2_76_0'>Yes<\/label><\/li><li class='gchoice_2_76_1'><input name='input_76' type='radio' value='No'  id='choice_2_76_1' tabindex='68'    \/><label for='choice_2_76_1' id='label_2_76_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_77' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you use CPAP machine?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_77'><li class='gchoice_2_77_0'><input name='input_77' type='radio' value='Yes'  id='choice_2_77_0' tabindex='69'    \/><label for='choice_2_77_0' id='label_2_77_0'>Yes<\/label><\/li><li class='gchoice_2_77_1'><input name='input_77' type='radio' value='No'  id='choice_2_77_1' tabindex='70'    \/><label for='choice_2_77_1' id='label_2_77_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_78' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3>Gastro-esophageal reflux symptoms.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_79' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have heartburn\/reflux?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_79'><li class='gchoice_2_79_0'><input name='input_79' type='radio' value='Yes'  id='choice_2_79_0' tabindex='71'    \/><label for='choice_2_79_0' id='label_2_79_0'>Yes<\/label><\/li><li class='gchoice_2_79_1'><input name='input_79' type='radio' value='No'  id='choice_2_79_1' tabindex='72'    \/><label for='choice_2_79_1' id='label_2_79_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_80' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_80' >Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_2_80' type='text' value='' class='medium'  tabindex='73'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_81' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_81' >What worsens the reflux?<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_2_81' type='text' value='' class='medium'  tabindex='74'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_83' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have reflux at night?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_83'><li class='gchoice_2_83_0'><input name='input_83' type='radio' value='Yes'  id='choice_2_83_0' tabindex='75'    \/><label for='choice_2_83_0' id='label_2_83_0'>Yes<\/label><\/li><li class='gchoice_2_83_1'><input name='input_83' type='radio' value='No'  id='choice_2_83_1' tabindex='76'    \/><label for='choice_2_83_1' id='label_2_83_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_84' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have hoarse voice?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_84'><li class='gchoice_2_84_0'><input name='input_84' type='radio' value='Yes'  id='choice_2_84_0' tabindex='77'    \/><label for='choice_2_84_0' id='label_2_84_0'>Yes<\/label><\/li><li class='gchoice_2_84_1'><input name='input_84' type='radio' value='No'  id='choice_2_84_1' tabindex='78'    \/><label for='choice_2_84_1' id='label_2_84_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_85' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you suffer from frequent sore throat?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_85'><li class='gchoice_2_85_0'><input name='input_85' type='radio' value='Yes'  id='choice_2_85_0' tabindex='79'    \/><label for='choice_2_85_0' id='label_2_85_0'>Yes<\/label><\/li><li class='gchoice_2_85_1'><input name='input_85' type='radio' value='No'  id='choice_2_85_1' tabindex='80'    \/><label for='choice_2_85_1' id='label_2_85_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_86' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have asthma or asthma like symptoms?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_86'><li class='gchoice_2_86_0'><input name='input_86' type='radio' value='Yes'  id='choice_2_86_0' tabindex='81'    \/><label for='choice_2_86_0' id='label_2_86_0'>Yes<\/label><\/li><li class='gchoice_2_86_1'><input name='input_86' type='radio' value='No'  id='choice_2_86_1' tabindex='82'    \/><label for='choice_2_86_1' id='label_2_86_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_87' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have frequent upper respiratory infections?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_87'><li class='gchoice_2_87_0'><input name='input_87' type='radio' value='Yes'  id='choice_2_87_0' tabindex='83'    \/><label for='choice_2_87_0' id='label_2_87_0'>Yes<\/label><\/li><li class='gchoice_2_87_1'><input name='input_87' type='radio' value='No'  id='choice_2_87_1' tabindex='84'    \/><label for='choice_2_87_1' id='label_2_87_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_88' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_88' >Treatment\/Medications<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_2_88' type='text' value='' class='medium'  tabindex='85'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_89' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Cardiovascular.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_90' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Shortness of breath<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_90'><li class='gchoice_2_90_0'><input name='input_90' type='radio' value='Yes'  id='choice_2_90_0' tabindex='86'    \/><label for='choice_2_90_0' id='label_2_90_0'>Yes<\/label><\/li><li class='gchoice_2_90_1'><input name='input_90' type='radio' value='No'  id='choice_2_90_1' tabindex='87'    \/><label for='choice_2_90_1' id='label_2_90_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_91' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Chest pain<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_91'><li class='gchoice_2_91_0'><input name='input_91' type='radio' value='Yes'  id='choice_2_91_0' tabindex='88'    \/><label for='choice_2_91_0' id='label_2_91_0'>Yes<\/label><\/li><li class='gchoice_2_91_1'><input name='input_91' type='radio' value='No'  id='choice_2_91_1' tabindex='89'    \/><label for='choice_2_91_1' id='label_2_91_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_92' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cardiac failure\/congestive heart failure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_92'><li class='gchoice_2_92_0'><input name='input_92' type='radio' value='Yes'  id='choice_2_92_0' tabindex='90'    \/><label for='choice_2_92_0' id='label_2_92_0'>Yes<\/label><\/li><li class='gchoice_2_92_1'><input name='input_92' type='radio' value='No'  id='choice_2_92_1' tabindex='91'    \/><label for='choice_2_92_1' id='label_2_92_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_93' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Fainting<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_93'><li class='gchoice_2_93_0'><input name='input_93' type='radio' value='Yes'  id='choice_2_93_0' tabindex='92'    \/><label for='choice_2_93_0' id='label_2_93_0'>Yes<\/label><\/li><li class='gchoice_2_93_1'><input name='input_93' type='radio' value='No'  id='choice_2_93_1' tabindex='93'    \/><label for='choice_2_93_1' id='label_2_93_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_94' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Tired while daily activities or during minimum effort<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_94'><li class='gchoice_2_94_0'><input name='input_94' type='radio' value='Yes'  id='choice_2_94_0' tabindex='94'    \/><label for='choice_2_94_0' id='label_2_94_0'>Yes<\/label><\/li><li class='gchoice_2_94_1'><input name='input_94' type='radio' value='No'  id='choice_2_94_1' tabindex='95'    \/><label for='choice_2_94_1' id='label_2_94_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_95' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >High blood pressure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_95'><li class='gchoice_2_95_0'><input name='input_95' type='radio' value='Yes'  id='choice_2_95_0' tabindex='96'    \/><label for='choice_2_95_0' id='label_2_95_0'>Yes<\/label><\/li><li class='gchoice_2_95_1'><input name='input_95' type='radio' value='No'  id='choice_2_95_1' tabindex='97'    \/><label for='choice_2_95_1' id='label_2_95_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_96' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Stroke<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_96'><li class='gchoice_2_96_0'><input name='input_96' type='radio' value='Yes'  id='choice_2_96_0' tabindex='98'    \/><label for='choice_2_96_0' id='label_2_96_0'>Yes<\/label><\/li><li class='gchoice_2_96_1'><input name='input_96' type='radio' value='No'  id='choice_2_96_1' tabindex='99'    \/><label for='choice_2_96_1' id='label_2_96_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_97' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cardiac surgery or catheterism<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_97'><li class='gchoice_2_97_0'><input name='input_97' type='radio' value='Yes'  id='choice_2_97_0' tabindex='100'    \/><label for='choice_2_97_0' id='label_2_97_0'>Yes<\/label><\/li><li class='gchoice_2_97_1'><input name='input_97' type='radio' value='No'  id='choice_2_97_1' tabindex='101'    \/><label for='choice_2_97_1' id='label_2_97_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_98' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Deep vein thrombosis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_98'><li class='gchoice_2_98_0'><input name='input_98' type='radio' value='Yes'  id='choice_2_98_0' tabindex='102'    \/><label for='choice_2_98_0' id='label_2_98_0'>Yes<\/label><\/li><li class='gchoice_2_98_1'><input name='input_98' type='radio' value='No'  id='choice_2_98_1' tabindex='103'    \/><label for='choice_2_98_1' id='label_2_98_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_99' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Pulmonary thromboembolism<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_99'><li class='gchoice_2_99_0'><input name='input_99' type='radio' value='Yes'  id='choice_2_99_0' tabindex='104'    \/><label for='choice_2_99_0' id='label_2_99_0'>Yes<\/label><\/li><li class='gchoice_2_99_1'><input name='input_99' type='radio' value='No'  id='choice_2_99_1' tabindex='105'    \/><label for='choice_2_99_1' id='label_2_99_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_100' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Varicose veins<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_100'><li class='gchoice_2_100_0'><input name='input_100' type='radio' value='Yes'  id='choice_2_100_0' tabindex='106'    \/><label for='choice_2_100_0' id='label_2_100_0'>Yes<\/label><\/li><li class='gchoice_2_100_1'><input name='input_100' type='radio' value='No'  id='choice_2_100_1' tabindex='107'    \/><label for='choice_2_100_1' id='label_2_100_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_101' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_101' >Treatment Medications<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_2_101' type='text' value='' class='medium'  tabindex='108'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_102' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Metabolic \/ rheumatic.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_103' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_103'><li class='gchoice_2_103_0'><input name='input_103' type='radio' value='Yes'  id='choice_2_103_0' tabindex='109'    \/><label for='choice_2_103_0' id='label_2_103_0'>Yes<\/label><\/li><li class='gchoice_2_103_1'><input name='input_103' type='radio' value='No'  id='choice_2_103_1' tabindex='110'    \/><label for='choice_2_103_1' id='label_2_103_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_104' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >High blood triglycerides<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_104'><li class='gchoice_2_104_0'><input name='input_104' type='radio' value='Yes'  id='choice_2_104_0' tabindex='111'    \/><label for='choice_2_104_0' id='label_2_104_0'>Yes<\/label><\/li><li class='gchoice_2_104_1'><input name='input_104' type='radio' value='No'  id='choice_2_104_1' tabindex='112'    \/><label for='choice_2_104_1' id='label_2_104_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_105' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >High blood cholesterol<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_105'><li class='gchoice_2_105_0'><input name='input_105' type='radio' value='Yes'  id='choice_2_105_0' tabindex='113'    \/><label for='choice_2_105_0' id='label_2_105_0'>Yes<\/label><\/li><li class='gchoice_2_105_1'><input name='input_105' type='radio' value='No'  id='choice_2_105_1' tabindex='114'    \/><label for='choice_2_105_1' id='label_2_105_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_106' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hypo\/Hyperthyroidism<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_106'><li class='gchoice_2_106_0'><input name='input_106' type='radio' value='Yes'  id='choice_2_106_0' tabindex='115'    \/><label for='choice_2_106_0' id='label_2_106_0'>Yes<\/label><\/li><li class='gchoice_2_106_1'><input name='input_106' type='radio' value='No'  id='choice_2_106_1' tabindex='116'    \/><label for='choice_2_106_1' id='label_2_106_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_107' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Gout<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_107'><li class='gchoice_2_107_0'><input name='input_107' type='radio' value='Yes'  id='choice_2_107_0' tabindex='117'    \/><label for='choice_2_107_0' id='label_2_107_0'>Yes<\/label><\/li><li class='gchoice_2_107_1'><input name='input_107' type='radio' value='No'  id='choice_2_107_1' tabindex='118'    \/><label for='choice_2_107_1' id='label_2_107_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_109' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Arthritis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_109'><li class='gchoice_2_109_0'><input name='input_109' type='radio' value='Yes'  id='choice_2_109_0' tabindex='119'    \/><label for='choice_2_109_0' id='label_2_109_0'>Yes<\/label><\/li><li class='gchoice_2_109_1'><input name='input_109' type='radio' value='No'  id='choice_2_109_1' tabindex='120'    \/><label for='choice_2_109_1' id='label_2_109_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_108' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Lupus<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_108'><li class='gchoice_2_108_0'><input name='input_108' type='radio' value='Yes'  id='choice_2_108_0' tabindex='121'    \/><label for='choice_2_108_0' id='label_2_108_0'>Yes<\/label><\/li><li class='gchoice_2_108_1'><input name='input_108' type='radio' value='No'  id='choice_2_108_1' tabindex='122'    \/><label for='choice_2_108_1' id='label_2_108_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_110' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Fibromialgia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_110'><li class='gchoice_2_110_0'><input name='input_110' type='radio' value='Yes'  id='choice_2_110_0' tabindex='123'    \/><label for='choice_2_110_0' id='label_2_110_0'>Yes<\/label><\/li><li class='gchoice_2_110_1'><input name='input_110' type='radio' value='No'  id='choice_2_110_1' tabindex='124'    \/><label for='choice_2_110_1' id='label_2_110_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_111' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Antiphospholipid syndrome<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_111'><li class='gchoice_2_111_0'><input name='input_111' type='radio' value='Yes'  id='choice_2_111_0' tabindex='125'    \/><label for='choice_2_111_0' id='label_2_111_0'>Yes<\/label><\/li><li class='gchoice_2_111_1'><input name='input_111' type='radio' value='No'  id='choice_2_111_1' tabindex='126'    \/><label for='choice_2_111_1' id='label_2_111_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_112' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_112'><li class='gchoice_2_112_0'><input name='input_112' type='radio' value='Yes'  id='choice_2_112_0' tabindex='127'    \/><label for='choice_2_112_0' id='label_2_112_0'>Yes<\/label><\/li><li class='gchoice_2_112_1'><input name='input_112' type='radio' value='No'  id='choice_2_112_1' tabindex='128'    \/><label for='choice_2_112_1' id='label_2_112_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_113' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Treatment\/Medication<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_113'><li class='gchoice_2_113_0'><input name='input_113' type='radio' value='Yes'  id='choice_2_113_0' tabindex='129'    \/><label for='choice_2_113_0' id='label_2_113_0'>Yes<\/label><\/li><li class='gchoice_2_113_1'><input name='input_113' type='radio' value='No'  id='choice_2_113_1' tabindex='130'    \/><label for='choice_2_113_1' id='label_2_113_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_114' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Pulmonary \/ respiratory.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_115' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Difficulty breathing<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_115'><li class='gchoice_2_115_0'><input name='input_115' type='radio' value='Yes'  id='choice_2_115_0' tabindex='131'    \/><label for='choice_2_115_0' id='label_2_115_0'>Yes<\/label><\/li><li class='gchoice_2_115_1'><input name='input_115' type='radio' value='No'  id='choice_2_115_1' tabindex='132'    \/><label for='choice_2_115_1' id='label_2_115_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_116' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Wheezing<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_116'><li class='gchoice_2_116_0'><input name='input_116' type='radio' value='Yes'  id='choice_2_116_0' tabindex='133'    \/><label for='choice_2_116_0' id='label_2_116_0'>Yes<\/label><\/li><li class='gchoice_2_116_1'><input name='input_116' type='radio' value='No'  id='choice_2_116_1' tabindex='134'    \/><label for='choice_2_116_1' id='label_2_116_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_117' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Asthma<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_117'><li class='gchoice_2_117_0'><input name='input_117' type='radio' value='Yes'  id='choice_2_117_0' tabindex='135'    \/><label for='choice_2_117_0' id='label_2_117_0'>Yes<\/label><\/li><li class='gchoice_2_117_1'><input name='input_117' type='radio' value='No'  id='choice_2_117_1' tabindex='136'    \/><label for='choice_2_117_1' id='label_2_117_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_118' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Previous pulmonary conditions<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_118'><li class='gchoice_2_118_0'><input name='input_118' type='radio' value='Yes'  id='choice_2_118_0' tabindex='137'    \/><label for='choice_2_118_0' id='label_2_118_0'>Yes<\/label><\/li><li class='gchoice_2_118_1'><input name='input_118' type='radio' value='No'  id='choice_2_118_1' tabindex='138'    \/><label for='choice_2_118_1' id='label_2_118_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_119' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_119' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_2_119' type='text' value='' class='medium'  tabindex='139'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_120' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_120' >Treatment\/medication<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_2_120' type='text' value='' class='medium'  tabindex='140'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_121' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Psychosocial.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_122' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Depression<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_122'><li class='gchoice_2_122_0'><input name='input_122' type='radio' value='Yes'  id='choice_2_122_0' tabindex='141'    \/><label for='choice_2_122_0' id='label_2_122_0'>Yes<\/label><\/li><li class='gchoice_2_122_1'><input name='input_122' type='radio' value='No'  id='choice_2_122_1' tabindex='142'    \/><label for='choice_2_122_1' id='label_2_122_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_123' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anxiety<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_123'><li class='gchoice_2_123_0'><input name='input_123' type='radio' value='Yes'  id='choice_2_123_0' tabindex='143'    \/><label for='choice_2_123_0' id='label_2_123_0'>Yes<\/label><\/li><li class='gchoice_2_123_1'><input name='input_123' type='radio' value='No'  id='choice_2_123_1' tabindex='144'    \/><label for='choice_2_123_1' id='label_2_123_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_124' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Difficulty sleeping<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_124'><li class='gchoice_2_124_0'><input name='input_124' type='radio' value='Yes'  id='choice_2_124_0' tabindex='145'    \/><label for='choice_2_124_0' id='label_2_124_0'>Yes<\/label><\/li><li class='gchoice_2_124_1'><input name='input_124' type='radio' value='No'  id='choice_2_124_1' tabindex='146'    \/><label for='choice_2_124_1' id='label_2_124_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_125' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Bulimia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_125'><li class='gchoice_2_125_0'><input name='input_125' type='radio' value='Yes'  id='choice_2_125_0' tabindex='147'    \/><label for='choice_2_125_0' id='label_2_125_0'>Yes<\/label><\/li><li class='gchoice_2_125_1'><input name='input_125' type='radio' value='No'  id='choice_2_125_1' tabindex='148'    \/><label for='choice_2_125_1' id='label_2_125_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_126' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anorexia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_126'><li class='gchoice_2_126_0'><input name='input_126' type='radio' value='Yes'  id='choice_2_126_0' tabindex='149'    \/><label for='choice_2_126_0' id='label_2_126_0'>Yes<\/label><\/li><li class='gchoice_2_126_1'><input name='input_126' type='radio' value='No'  id='choice_2_126_1' tabindex='150'    \/><label for='choice_2_126_1' id='label_2_126_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_127' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >OCD<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_127'><li class='gchoice_2_127_0'><input name='input_127' type='radio' value='Yes'  id='choice_2_127_0' tabindex='151'    \/><label for='choice_2_127_0' id='label_2_127_0'>Yes<\/label><\/li><li class='gchoice_2_127_1'><input name='input_127' type='radio' value='No'  id='choice_2_127_1' tabindex='152'    \/><label for='choice_2_127_1' id='label_2_127_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_128' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_128' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_2_128' type='text' value='' class='medium'  tabindex='153'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_129' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_129' >Treatment \/ Medications<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_2_129' type='text' value='' class='medium'  tabindex='154'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_130' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Family history.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_131' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of cancer<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_131'><li class='gchoice_2_131_0'><input name='input_131' type='radio' value='Yes'  id='choice_2_131_0' tabindex='155'    \/><label for='choice_2_131_0' id='label_2_131_0'>Yes<\/label><\/li><li class='gchoice_2_131_1'><input name='input_131' type='radio' value='No'  id='choice_2_131_1' tabindex='156'    \/><label for='choice_2_131_1' id='label_2_131_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_132' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_132' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_2_132' type='text' value='' class='medium'  tabindex='157'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_133' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of high blood pressure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_133'><li class='gchoice_2_133_0'><input name='input_133' type='radio' value='Yes'  id='choice_2_133_0' tabindex='158'    \/><label for='choice_2_133_0' id='label_2_133_0'>Yes<\/label><\/li><li class='gchoice_2_133_1'><input name='input_133' type='radio' value='No'  id='choice_2_133_1' tabindex='159'    \/><label for='choice_2_133_1' id='label_2_133_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_134' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_134' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_2_134' type='text' value='' class='medium'  tabindex='160'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_135' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_135'><li class='gchoice_2_135_0'><input name='input_135' type='radio' value='Yes'  id='choice_2_135_0' tabindex='161'    \/><label for='choice_2_135_0' id='label_2_135_0'>Yes<\/label><\/li><li class='gchoice_2_135_1'><input name='input_135' type='radio' value='No'  id='choice_2_135_1' tabindex='162'    \/><label for='choice_2_135_1' id='label_2_135_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_136' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_136' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_2_136' type='text' value='' class='medium'  tabindex='163'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_137' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of high blood triglycerides<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_137'><li class='gchoice_2_137_0'><input name='input_137' type='radio' value='Yes'  id='choice_2_137_0' tabindex='164'    \/><label for='choice_2_137_0' id='label_2_137_0'>Yes<\/label><\/li><li class='gchoice_2_137_1'><input name='input_137' type='radio' value='No'  id='choice_2_137_1' tabindex='165'    \/><label for='choice_2_137_1' id='label_2_137_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_138' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_138' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_2_138' type='text' value='' class='medium'  tabindex='166'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_142' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of high blood cholesterol<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_142'><li class='gchoice_2_142_0'><input name='input_142' type='radio' value='Yes'  id='choice_2_142_0' tabindex='167'    \/><label for='choice_2_142_0' id='label_2_142_0'>Yes<\/label><\/li><li class='gchoice_2_142_1'><input name='input_142' type='radio' value='No'  id='choice_2_142_1' tabindex='168'    \/><label for='choice_2_142_1' id='label_2_142_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_141' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_141' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_2_141' type='text' value='' class='medium'  tabindex='169'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_143' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Family history of obesity<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_143'><li class='gchoice_2_143_0'><input name='input_143' type='radio' value='Yes'  id='choice_2_143_0' tabindex='170'    \/><label for='choice_2_143_0' id='label_2_143_0'>Yes<\/label><\/li><li class='gchoice_2_143_1'><input name='input_143' type='radio' value='No'  id='choice_2_143_1' tabindex='171'    \/><label for='choice_2_143_1' id='label_2_143_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_140' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_140' >Please specify which family member<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_2_140' type='text' value='' class='medium'  tabindex='172'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_144' class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3> Other medical history.<\/h3>\n<p>(Please check the boxes that apply to you)<\/p><\/li><li id='field_2_145' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hospitalizations<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_145'><li class='gchoice_2_145_0'><input name='input_145' type='radio' value='Yes'  id='choice_2_145_0' tabindex='173'    \/><label for='choice_2_145_0' id='label_2_145_0'>Yes<\/label><\/li><li class='gchoice_2_145_1'><input name='input_145' type='radio' value='No'  id='choice_2_145_1' tabindex='174'    \/><label for='choice_2_145_1' id='label_2_145_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_173' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_173' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_2_173' type='text' value='' class='medium'  tabindex='175'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_146' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Traumatic Injuries\/bone fractures<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_146'><li class='gchoice_2_146_0'><input name='input_146' type='radio' value='Yes'  id='choice_2_146_0' tabindex='176'    \/><label for='choice_2_146_0' id='label_2_146_0'>Yes<\/label><\/li><li class='gchoice_2_146_1'><input name='input_146' type='radio' value='No'  id='choice_2_146_1' tabindex='177'    \/><label for='choice_2_146_1' id='label_2_146_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_174' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_174' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_2_174' type='text' value='' class='medium'  tabindex='178'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_147' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Surgeries<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_147'><li class='gchoice_2_147_0'><input name='input_147' type='radio' value='Yes'  id='choice_2_147_0' tabindex='179'    \/><label for='choice_2_147_0' id='label_2_147_0'>Yes<\/label><\/li><li class='gchoice_2_147_1'><input name='input_147' type='radio' value='No'  id='choice_2_147_1' tabindex='180'    \/><label for='choice_2_147_1' id='label_2_147_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_175' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_175' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_2_175' type='text' value='' class='medium'  tabindex='181'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_148' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Blood Transfusions<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_148'><li class='gchoice_2_148_0'><input name='input_148' type='radio' value='Yes'  id='choice_2_148_0' tabindex='182'    \/><label for='choice_2_148_0' id='label_2_148_0'>Yes<\/label><\/li><li class='gchoice_2_148_1'><input name='input_148' type='radio' value='No'  id='choice_2_148_1' tabindex='183'    \/><label for='choice_2_148_1' id='label_2_148_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_176' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_176' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_2_176' type='text' value='' class='medium'  tabindex='184'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_149' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Adverse reaction to blood transfusion<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_149'><li class='gchoice_2_149_0'><input name='input_149' type='radio' value='Yes'  id='choice_2_149_0' tabindex='185'    \/><label for='choice_2_149_0' id='label_2_149_0'>Yes<\/label><\/li><li class='gchoice_2_149_1'><input name='input_149' type='radio' value='No'  id='choice_2_149_1' tabindex='186'    \/><label for='choice_2_149_1' id='label_2_149_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_177' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_177' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_2_177' type='text' value='' class='medium'  tabindex='187'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_151' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Kidney disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_151'><li class='gchoice_2_151_0'><input name='input_151' type='radio' value='Yes'  id='choice_2_151_0' tabindex='188'    \/><label for='choice_2_151_0' id='label_2_151_0'>Yes<\/label><\/li><li class='gchoice_2_151_1'><input name='input_151' type='radio' value='No'  id='choice_2_151_1' tabindex='189'    \/><label for='choice_2_151_1' id='label_2_151_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_178' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_178' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_2_178' type='text' value='' class='medium'  tabindex='190'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_153' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hepatitis or liver disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_153'><li class='gchoice_2_153_0'><input name='input_153' type='radio' value='Yes'  id='choice_2_153_0' tabindex='191'    \/><label for='choice_2_153_0' id='label_2_153_0'>Yes<\/label><\/li><li class='gchoice_2_153_1'><input name='input_153' type='radio' value='No'  id='choice_2_153_1' tabindex='192'    \/><label for='choice_2_153_1' id='label_2_153_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_179' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_179' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_2_179' type='text' value='' class='medium'  tabindex='193'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_158' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Anemia or bleeding disorder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_158'><li class='gchoice_2_158_0'><input name='input_158' type='radio' value='Yes'  id='choice_2_158_0' tabindex='194'    \/><label for='choice_2_158_0' id='label_2_158_0'>Yes<\/label><\/li><li class='gchoice_2_158_1'><input name='input_158' type='radio' value='No'  id='choice_2_158_1' tabindex='195'    \/><label for='choice_2_158_1' id='label_2_158_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_180' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_180' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_2_180' type='text' value='' class='medium'  tabindex='196'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_155' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Dialysis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_155'><li class='gchoice_2_155_0'><input name='input_155' type='radio' value='Yes'  id='choice_2_155_0' tabindex='197'    \/><label for='choice_2_155_0' id='label_2_155_0'>Yes<\/label><\/li><li class='gchoice_2_155_1'><input name='input_155' type='radio' value='No'  id='choice_2_155_1' tabindex='198'    \/><label for='choice_2_155_1' id='label_2_155_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_181' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_181' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_2_181' type='text' value='' class='medium'  tabindex='199'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_160' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you wear a colostomy bag?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_160'><li class='gchoice_2_160_0'><input name='input_160' type='radio' value='Yes'  id='choice_2_160_0' tabindex='200'    \/><label for='choice_2_160_0' id='label_2_160_0'>Yes<\/label><\/li><li class='gchoice_2_160_1'><input name='input_160' type='radio' value='No'  id='choice_2_160_1' tabindex='201'    \/><label for='choice_2_160_1' id='label_2_160_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_182' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_182' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_2_182' type='text' value='' class='medium'  tabindex='202'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_162' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Hearing impairment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_162'><li class='gchoice_2_162_0'><input name='input_162' type='radio' value='Yes'  id='choice_2_162_0' tabindex='203'    \/><label for='choice_2_162_0' id='label_2_162_0'>Yes<\/label><\/li><li class='gchoice_2_162_1'><input name='input_162' type='radio' value='No'  id='choice_2_162_1' tabindex='204'    \/><label for='choice_2_162_1' id='label_2_162_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_183' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_183' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_2_183' type='text' value='' class='medium'  tabindex='205'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_164' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Vision impairment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_164'><li class='gchoice_2_164_0'><input name='input_164' type='radio' value='Yes'  id='choice_2_164_0' tabindex='206'    \/><label for='choice_2_164_0' id='label_2_164_0'>Yes<\/label><\/li><li class='gchoice_2_164_1'><input name='input_164' type='radio' value='No'  id='choice_2_164_1' tabindex='207'    \/><label for='choice_2_164_1' id='label_2_164_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_163' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_163' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_2_163' type='text' value='' class='medium'  tabindex='208'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_165' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Movement impairment<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_165'><li class='gchoice_2_165_0'><input name='input_165' type='radio' value='Yes'  id='choice_2_165_0' tabindex='209'    \/><label for='choice_2_165_0' id='label_2_165_0'>Yes<\/label><\/li><li class='gchoice_2_165_1'><input name='input_165' type='radio' value='No'  id='choice_2_165_1' tabindex='210'    \/><label for='choice_2_165_1' id='label_2_165_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_166' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_166' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_2_166' type='text' value='' class='medium'  tabindex='211'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_167' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Von Willebrand disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_167'><li class='gchoice_2_167_0'><input name='input_167' type='radio' value='Yes'  id='choice_2_167_0' tabindex='212'    \/><label for='choice_2_167_0' id='label_2_167_0'>Yes<\/label><\/li><li class='gchoice_2_167_1'><input name='input_167' type='radio' value='No'  id='choice_2_167_1' tabindex='213'    \/><label for='choice_2_167_1' id='label_2_167_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_169' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_169' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_2_169' type='text' value='' class='medium'  tabindex='214'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_170' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Amputations<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_170'><li class='gchoice_2_170_0'><input name='input_170' type='radio' value='Yes'  id='choice_2_170_0' tabindex='215'    \/><label for='choice_2_170_0' id='label_2_170_0'>Yes<\/label><\/li><li class='gchoice_2_170_1'><input name='input_170' type='radio' value='No'  id='choice_2_170_1' tabindex='216'    \/><label for='choice_2_170_1' id='label_2_170_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_2_168' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_168' >If yes, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_2_168' type='text' value='' class='medium'  tabindex='217'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_171' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_171' >Other<\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_2_171' type='text' value='' class='medium'  tabindex='218'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_172' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_2_172' >Other medications not listed above<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_2_172' type='text' value='' class='medium'  tabindex='219'    aria-invalid=\"false\" \/><\/div><\/li><li id='field_2_184' class='gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_' ><label class='gfield_label' for='input_2_184' >Comments<\/label><div class='ginput_container'><input name='input_184' id='input_2_184' type='text' value='' \/><\/div><div class='gfield_description'>This field is for validation purposes and should be left unchanged.<\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit' tabindex='220' onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=1' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input 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