{"id":1149,"date":"2025-03-21T16:19:05","date_gmt":"2025-03-21T20:19:05","guid":{"rendered":"https:\/\/hyperbaricphp.com\/?page_id=1149"},"modified":"2025-03-21T18:12:14","modified_gmt":"2025-03-21T22:12:14","slug":"patient-intake-2","status":"publish","type":"page","link":"https:\/\/hyperbaricphp.com\/?page_id=1149","title":{"rendered":"Patient Intake"},"content":{"rendered":"\n<p><strong>Welcome to Hyperbaric PHP!<\/strong> We&#8217;re thrilled to have you join us on your wellness journey. To personalize your hyperbaric therapy experience and ensure the best possible care, please take a few moments to carefully review, fill out, and sign this form. The information you provide will help us tailor your treatment plan and optimize your experience at Hyperbaric PHP.<\/p>\n\n\n<div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ff_has_v3_recptcha ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" data-recptcha_key=\"6Le24hQrAAAAAMqY5jwpbMnFNfYU1Z2D-v1tY8uU\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Hyperbaric PHP Patient Intake Form<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_3_item_sf\" aria-label=\"Notify\">\n                    Notify                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_3__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_3_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='1149' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"6ea6b13fae\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1149\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\" data-pm-slice=\"1 1 []\"><strong>Please continue if:<\/strong><\/p>\n<div class=\"jseditor-contract-line jseditor-contract-line-paragraph-font margin-bottom-05 jseditor-list-item-UL-depth-1 jseditor-counter-reset-depth-1 jseditor-depth-1\" data-depth=\"1\" data-list-item=\"UL\">You are not currently prescribed or taking any of the following medications: <strong>Bleomycin, Disulfiram, Mafernide Acetate<\/strong><\/div>\n<div class=\"jseditor-contract-line jseditor-contract-line-paragraph-font margin-bottom-05 jseditor-list-item-UL-depth-1 jseditor-counter-reset-depth-1 jseditor-depth-1\" data-depth=\"1\" data-list-item=\"UL\">You do not have a history of, or suspect you may have, any of the following conditions: <strong>Hereditary Sperocytosis, Sickle Cell Anemia, COPD<\/strong><\/div>\n<div data-depth=\"1\" data-list-item=\"UL\">\u00a0<\/div>\n<div data-depth=\"1\" data-list-item=\"UL\">\u00a0<\/div><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description' id='label_ff_3_description' aria-label=\"What is your primary reason for visiting Hyperbaric PHP?\">What is your primary reason for visiting Hyperbaric PHP?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description\" name=\"description\" id=\"ff_3_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_2' id='label_ff_3_dropdown_2' aria-label=\"How did you find us?\">How did you find us?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_3_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_2\"><option value=\"\">- Select -<\/option><option value=\"Internet\"  >Internet<\/option><option value=\"Social Media\"  >Social Media<\/option><option value=\"Referral\"  >Referral<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text' aria-label=\"Referred By\">Referred By<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_2\" ><h3 class='ff-el-section-title'>1. Patient Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' id='label_ff_3_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_middle_name_' id='label_ff_3_names_middle_name_' >Middle Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[middle_name]\" id=\"ff_3_names_middle_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Middle Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' id='label_ff_3_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mask' id='label_ff_3_input_mask' aria-label=\"Date of Birth (MM\/DD\/YYYY)\">Date of Birth (MM\/DD\/YYYY)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask\" data-mask=\"00\/00\/0000\" class=\"ff-el-form-control\" data-name=\"input_mask\" id=\"ff_3_input_mask\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_1' id='label_ff_3_dropdown_1' aria-label=\"Marital Status\">Marital Status<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_1\"><option value=\"\">- Select -<\/option><option value=\"Single\"  >Single<\/option><option value=\"Married\"  >Married<\/option><option value=\"Widowed\"  >Widowed<\/option><option value=\"Separated\"  >Separated<\/option><option value=\"Divorced \"  >Divorced<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email_1' id='label_ff_3_email_1' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_3_email_1\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mask_4' id='label_ff_3_input_mask_4' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask_4\" data-mask=\"(000) 000-0000\" class=\"ff-el-form-control\" data-name=\"input_mask_4\" id=\"ff_3_input_mask_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_address_line_1_' id='label_ff_3_address_1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_3_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Address Line 1\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_address_line_2_' id='label_ff_3_address_1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_3_address_1_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Address Line 2\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_city_' id='label_ff_3_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_3_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_state_' id='label_ff_3_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_3_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_zip_' id='label_ff_3_address_1_zip_' aria-label=\"Zip Code\">Zip Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_3_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Zip\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_country_' id='label_ff_3_address_1_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_3_address_1_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=false><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='RE' >R\u00e9union<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_3\" ><h3 class='ff-el-section-title'>2. Parent\/Legal Guardian Information<\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\" data-pm-slice=\"1 1 []\">Complete this section only if you are signing this form as the legal representative of a minor.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 30.95%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown' id='label_ff_3_dropdown' aria-label=\"Relationship to Patient\">Relationship to Patient<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_3_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown\"><option value=\"\">- Select -<\/option><option value=\"Parent\"  >Parent<\/option><option value=\"Legal Guardian\"  >Legal Guardian<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 69.05%;'><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_1_first_name_' id='label_ff_3_names_1_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_3_names_1_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_1_last_name_' id='label_ff_3_names_1_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_3_names_1_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_email' id='label_ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_mask_1' id='label_ff_3_input_mask_1' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask_1\" data-mask=\"(000) 000-0000\" class=\"ff-el-form-control\" data-name=\"input_mask_1\" id=\"ff_3_input_mask_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_4\" ><h3 class='ff-el-section-title'>3. Emergency Contact Information<\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\" data-pm-slice=\"1 1 []\">If the emergency contact is not the same as the parent\/guardian listed above, please complete this section<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50.27%;'><div data-type=\"name-element\" data-name=\"names_2\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_2_first_name_' id='label_ff_3_names_2_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[first_name]\" id=\"ff_3_names_2_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_2_last_name_' id='label_ff_3_names_2_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[last_name]\" id=\"ff_3_names_2_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 26.24%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_email_2' id='label_ff_3_email_2' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_2\" id=\"ff_3_email_2\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 23.49%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_mask_2' id='label_ff_3_input_mask_2' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask_2\" data-mask=\"(000) 000-0000\" class=\"ff-el-form-control\" data-name=\"input_mask_2\" id=\"ff_3_input_mask_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_5\" ><h3 class='ff-el-section-title'>4. Physician Information<\/h3><div class='ff-section_break_desk'><p>Please provide your primary physician information.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 31.06%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_3' id='label_ff_3_dropdown_3' aria-label=\"Are you currently under doctor&#039;s care?\">Are you currently under doctor's care?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_3_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_dropdown_3\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 47.97%;'><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_3_first_name_' id='label_ff_3_names_3_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_3_names_3_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_names_3_last_name_' id='label_ff_3_names_3_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[last_name]\" id=\"ff_3_names_3_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 20.97%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_mask_3' id='label_ff_3_input_mask_3' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask_3\" data-mask=\"(00) 0000-0000\" class=\"ff-el-form-control\" data-name=\"input_mask_3\" id=\"ff_3_input_mask_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_email_3' id='label_ff_3_email_3' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_3\" id=\"ff_3_email_3\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email_3\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_url' id='label_ff_3_url' aria-label=\"Website\">Website<\/label><\/div><div class='ff-el-input--content'><input type=\"url\" name=\"url\" class=\"ff-el-form-control\" data-name=\"url\" id=\"ff_3_url\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_6\" ><h3 class='ff-el-section-title'>5. Patient Medical Screening<\/h3><div class='ff-section_break_desk'><p>Please provide us as much infromation as possible.<\/p><\/div><hr \/><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_4' id='label_ff_3_dropdown_4' aria-label=\"Are you currently under medical treatment?\">Are you currently under medical treatment?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_3_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_4\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_6' id='label_ff_3_dropdown_6' aria-label=\"Do you use tabacco or vape products?\">Do you use tabacco or vape products?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_6\" id=\"ff_3_dropdown_6\" class=\"ff-el-form-control\" data-name=\"dropdown_6\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_6\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_5' id='label_ff_3_dropdown_5' aria-label=\"Are you taking any medications?\">Are you taking any medications?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_5\" id=\"ff_3_dropdown_5\" class=\"ff-el-form-control\" data-name=\"dropdown_5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_5\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_7' id='label_ff_3_dropdown_7' aria-label=\"Do you use alcohol?\">Do you use alcohol?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_7\" id=\"ff_3_dropdown_7\" class=\"ff-el-form-control\" data-name=\"dropdown_7\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_7\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_1' id='label_ff_3_description_1' aria-label=\"List of medications\">List of medications<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_1\" name=\"description_1\" id=\"ff_3_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_2' id='label_ff_3_description_2' aria-label=\"How often do you exercise?\">How often do you exercise?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_2\" name=\"description_2\" id=\"ff_3_description_2\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_3' id='label_ff_3_description_3' aria-label=\"How often do you use alcohol?\">How often do you use alcohol?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_3\" name=\"description_3\" id=\"ff_3_description_3\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_3\" ><\/textarea><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_5' id='label_ff_3_description_5' aria-label=\"List any medications you are allergic to:\">List any medications you are allergic to:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_5\" name=\"description_5\" id=\"ff_3_description_5\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_5\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_4' id='label_ff_3_description_4' aria-label=\"Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please describe below.\">Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please describe below.<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_4\" name=\"description_4\" id=\"ff_3_description_4\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_4\" ><\/textarea><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_8' id='label_ff_3_dropdown_8' aria-label=\"Are you currently pregnant?\">Are you currently pregnant?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_8\" id=\"ff_3_dropdown_8\" class=\"ff-el-form-control\" data-name=\"dropdown_8\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_8\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25.07%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric_field' id='label_ff_3_numeric_field' aria-label=\"If yes, how many weeks?\">If yes, how many weeks?<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_3_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 41.6%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime' id='label_ff_3_datetime' aria-label=\"If no: When was your Last Menstrual Period (LMP)?\">If no: When was your Last Menstrual Period (LMP)?<\/label><\/div><div class='ff-el-input--content'><input  aria-label='If no: When was your Last Menstrual Period (LMP)? Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_7\" ><h3 class='ff-el-section-title'>Please select if you had any of the following conditions.<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Acute Respiratory Illness\">Acute Respiratory Illness<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_20830ac21991c2ef922d357328461dc7'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_20830ac21991c2ef922d357328461dc7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_f36a8ca7d1fa7b9532a24f5d8889dd33'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_f36a8ca7d1fa7b9532a24f5d8889dd33' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"AIDS or HIV Infection\">AIDS or HIV Infection<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_856ba8d375312eef15c2cc905f4d139f'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_856ba8d375312eef15c2cc905f4d139f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_58a0aa57f24efbdb47dfdc3f4f561266'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_58a0aa57f24efbdb47dfdc3f4f561266' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Anemia\">Anemia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_daf1c266417ec86517cc56bbcdc7bf81'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_1_daf1c266417ec86517cc56bbcdc7bf81' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_6ceb6be08fa67b2c9dc69a86f6f7bf15'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_1_6ceb6be08fa67b2c9dc69a86f6f7bf15' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Angina\">Angina<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_c05e54e9a5de11bcbee8d3d04970e8d7'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_4_c05e54e9a5de11bcbee8d3d04970e8d7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_13002ba5d4a3bb20523655085c0776c4'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_4_13002ba5d4a3bb20523655085c0776c4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Anxiety\">Anxiety<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_1c548d6c7a987dbc69f30393d95e1e60'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_5_1c548d6c7a987dbc69f30393d95e1e60' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_c6ca8d7118172212052e24cd96127c4c'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_5_c6ca8d7118172212052e24cd96127c4c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Arthritis\">Arthritis<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_57c58e3b800a379a5d7ec8b141107344'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_6_57c58e3b800a379a5d7ec8b141107344' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_6_7062525fb2d99f964364bc2f1cb67457'><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_6_7062525fb2d99f964364bc2f1cb67457' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Asthma\">Asthma<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_bbe1d3c9f0c601c1a230508cdde15357'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_7_bbe1d3c9f0c601c1a230508cdde15357' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_7aa9b46664a18e6755a2062a4e1b6f9e'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_7_7aa9b46664a18e6755a2062a4e1b6f9e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Cancer\">Cancer<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_e1b58ada4ffaf3b7d428a161b2451f7e'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_8_e1b58ada4ffaf3b7d428a161b2451f7e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_c71b1d8180e7b92e362dfe50af151a76'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_8_c71b1d8180e7b92e362dfe50af151a76' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Back Pain\">Back Pain<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_4c1948093b95816d678676bb31b95cd5'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_9_4c1948093b95816d678676bb31b95cd5' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_4852caf232a3c8eaea1a4572833528bf'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_9_4852caf232a3c8eaea1a4572833528bf' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Checmical Sensitivity\">Checmical Sensitivity<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_8f1ed4b0ce39580f9d3b36d6063334d5'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_10_8f1ed4b0ce39580f9d3b36d6063334d5' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_8ca94d81588681c7475a7fd3f39d0158'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_10_8ca94d81588681c7475a7fd3f39d0158' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Chest Pain\">Chest Pain<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_7312bf632899750448650a9da3fc3fcd'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_11_7312bf632899750448650a9da3fc3fcd' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_14c202781a4704a58c922192fb3bfcc8'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_11_14c202781a4704a58c922192fb3bfcc8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Chronic Bronchitis\">Chronic Bronchitis<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_cd62ed90b34c021a3f28194efc4b2e85'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_12_cd62ed90b34c021a3f28194efc4b2e85' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_6295757b5e6e74b2ca2024635fd9943e'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_12_6295757b5e6e74b2ca2024635fd9943e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Chronic Fatigue (CFS)\">Chronic Fatigue (CFS)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_dde4dbf7d83e9443d07f86e3f18ed555'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_13_dde4dbf7d83e9443d07f86e3f18ed555' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_f582e9a93c9aeacb6f2287e508c06885'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_13_f582e9a93c9aeacb6f2287e508c06885' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Claustrophobia\">Claustrophobia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_8522f8489d2de27392b90b4b60b1c49c'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_14_8522f8489d2de27392b90b4b60b1c49c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_bda41f9f64214029c7737e594cafc862'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_14_bda41f9f64214029c7737e594cafc862' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Diabetes \u2013 Insulin Dependent\">Diabetes \u2013 Insulin Dependent<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_9e3a42b5d6180be14083e33398cde96e'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_15_9e3a42b5d6180be14083e33398cde96e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_fdd4709c55e924e10c5896067a12b746'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_15_fdd4709c55e924e10c5896067a12b746' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Fainting \/ Seizures\">Fainting \/ Seizures<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_92dbe1bab0b4ba65788f1112daa9a27d'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_18_92dbe1bab0b4ba65788f1112daa9a27d' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_18_f3f1ee84ac4fe2c35ba53cfe0f9baedb'><input  type=\"radio\" name=\"input_radio_18\" data-name=\"input_radio_18\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_18_f3f1ee84ac4fe2c35ba53cfe0f9baedb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Emphysema\">Emphysema<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_16_44379945a95745e824b6c80e6f031bb9'><input  type=\"radio\" name=\"input_radio_16\" data-name=\"input_radio_16\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_16_44379945a95745e824b6c80e6f031bb9' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_16_3e02a54a0e805605d64cdcde9ee28a06'><input  type=\"radio\" name=\"input_radio_16\" data-name=\"input_radio_16\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_16_3e02a54a0e805605d64cdcde9ee28a06' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Fever Related Seizures\">Fever Related Seizures<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_26734ade2a5b7228f1d2126d6dab8704'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_17_26734ade2a5b7228f1d2126d6dab8704' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_17_a8be7ecfb2406e13ee0740cb704cec7e'><input  type=\"radio\" name=\"input_radio_17\" data-name=\"input_radio_17\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_17_a8be7ecfb2406e13ee0740cb704cec7e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Fibromyalgia\">Fibromyalgia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_6bf71394d2ad7221afa2bbfefe03e120'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_19_6bf71394d2ad7221afa2bbfefe03e120' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_19_668b1ae8dbb8b7ad53e623ae3b298c02'><input  type=\"radio\" name=\"input_radio_19\" data-name=\"input_radio_19\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_19_668b1ae8dbb8b7ad53e623ae3b298c02' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Frequent Ear Infections\">Frequent Ear Infections<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_20_5e7bbeddd6fac39715216cc5299b28c0'><input  type=\"radio\" name=\"input_radio_20\" data-name=\"input_radio_20\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_20_5e7bbeddd6fac39715216cc5299b28c0' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_20_7edf235db2a3f4ebb71ab3104730cf94'><input  type=\"radio\" name=\"input_radio_20\" data-name=\"input_radio_20\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_20_7edf235db2a3f4ebb71ab3104730cf94' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Frequently Tired\">Frequently Tired<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_21_55ab907efa765ce08114fc1819dc03c3'><input  type=\"radio\" name=\"input_radio_21\" data-name=\"input_radio_21\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_21_55ab907efa765ce08114fc1819dc03c3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_21_3248befd8481b850040e0d020725d4fb'><input  type=\"radio\" name=\"input_radio_21\" data-name=\"input_radio_21\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_21_3248befd8481b850040e0d020725d4fb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Glaucoma\">Glaucoma<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_22_6ccc5a0e829970e9f724b740070c26dc'><input  type=\"radio\" name=\"input_radio_22\" data-name=\"input_radio_22\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_22_6ccc5a0e829970e9f724b740070c26dc' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_22_af59e16f98bb2d39f01ebae322394e6d'><input  type=\"radio\" name=\"input_radio_22\" data-name=\"input_radio_22\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_22_af59e16f98bb2d39f01ebae322394e6d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Hay Fever\/Allergies\">Hay Fever\/Allergies<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_23_db59bea0506f61d1e8fb3148f99302d3'><input  type=\"radio\" name=\"input_radio_23\" data-name=\"input_radio_23\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_23_db59bea0506f61d1e8fb3148f99302d3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_23_a97519e91cfe1f5abf07e44afd4c7104'><input  type=\"radio\" name=\"input_radio_23\" data-name=\"input_radio_23\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_23_a97519e91cfe1f5abf07e44afd4c7104' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Hepatitis\/Jaundice\">Hepatitis\/Jaundice<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_24_913bcf32180e7a6f4fa041364078c538'><input  type=\"radio\" name=\"input_radio_24\" data-name=\"input_radio_24\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_24_913bcf32180e7a6f4fa041364078c538' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_24_c5418ddc07742f953e6e5e744c60d412'><input  type=\"radio\" name=\"input_radio_24\" data-name=\"input_radio_24\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_24_c5418ddc07742f953e6e5e744c60d412' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Heart Attack\">Heart Attack<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_25_332e6e9b0e07b80add9c0a0c9f86e5d1'><input  type=\"radio\" name=\"input_radio_25\" data-name=\"input_radio_25\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_25_332e6e9b0e07b80add9c0a0c9f86e5d1' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_25_cd9707048e43acaaf25e1e91e1294ee8'><input  type=\"radio\" name=\"input_radio_25\" data-name=\"input_radio_25\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_25_cd9707048e43acaaf25e1e91e1294ee8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Heart Murmur\">Heart Murmur<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_26_dcd153a7a23fb20e4c0e2733c8c11814'><input  type=\"radio\" name=\"input_radio_26\" data-name=\"input_radio_26\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_26_dcd153a7a23fb20e4c0e2733c8c11814' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_26_ff8b22b7e94d3330ddd6fce6ec5f4456'><input  type=\"radio\" name=\"input_radio_26\" data-name=\"input_radio_26\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_26_ff8b22b7e94d3330ddd6fce6ec5f4456' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Heart Problems\">Heart Problems<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_27_d74768f7372d0c931e172c2770d94d06'><input  type=\"radio\" name=\"input_radio_27\" data-name=\"input_radio_27\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_27_d74768f7372d0c931e172c2770d94d06' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_27_0f2e8a0a5733795f78acac35392ba21d'><input  type=\"radio\" name=\"input_radio_27\" data-name=\"input_radio_27\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_27_0f2e8a0a5733795f78acac35392ba21d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"High Blood Pressure\">High Blood Pressure<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_28_a90bd632a5a9697550717d8cfb6f106d'><input  type=\"radio\" name=\"input_radio_28\" data-name=\"input_radio_28\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_28_a90bd632a5a9697550717d8cfb6f106d' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_28_8b7fd7a96f1ce90b7c9e27e267136720'><input  type=\"radio\" name=\"input_radio_28\" data-name=\"input_radio_28\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_28_8b7fd7a96f1ce90b7c9e27e267136720' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Frequent Infections\">Frequent Infections<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_29_5f26a7c676b098d58b53f08699862693'><input  type=\"radio\" name=\"input_radio_29\" data-name=\"input_radio_29\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_29_5f26a7c676b098d58b53f08699862693' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_29_4e3de037cd4a7cb1317cb2721b6ce5e2'><input  type=\"radio\" name=\"input_radio_29\" data-name=\"input_radio_29\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_29_4e3de037cd4a7cb1317cb2721b6ce5e2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Kidney Disease\">Kidney Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_30_673a4eba8a6184b49736aaa606e80352'><input  type=\"radio\" name=\"input_radio_30\" data-name=\"input_radio_30\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_30_673a4eba8a6184b49736aaa606e80352' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_30_59ea2ae33aee26452bb09a706c93cb23'><input  type=\"radio\" name=\"input_radio_30\" data-name=\"input_radio_30\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_30_59ea2ae33aee26452bb09a706c93cb23' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Leukemia\">Leukemia<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_31_04b4931d456ce62ab36842e5ae4612a8'><input  type=\"radio\" name=\"input_radio_31\" data-name=\"input_radio_31\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_31_04b4931d456ce62ab36842e5ae4612a8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_31_416ea7bc512df7fd59a714e9a04701be'><input  type=\"radio\" name=\"input_radio_31\" data-name=\"input_radio_31\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_31_416ea7bc512df7fd59a714e9a04701be' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Liver Disease\">Liver Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_32_cac04206735eabe2afe6301d803438cd'><input  type=\"radio\" name=\"input_radio_32\" data-name=\"input_radio_32\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_32_cac04206735eabe2afe6301d803438cd' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_32_4fbbc7a3bdeee7b41fc5c5fe2a47a94e'><input  type=\"radio\" name=\"input_radio_32\" data-name=\"input_radio_32\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_32_4fbbc7a3bdeee7b41fc5c5fe2a47a94e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Low Blood Pressure\">Low Blood Pressure<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_33_4d3cb37d636f7c27fdbc96f7d25247cd'><input  type=\"radio\" name=\"input_radio_33\" data-name=\"input_radio_33\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_33_4d3cb37d636f7c27fdbc96f7d25247cd' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_33_381dd55cc3515c7840a80ed1988bc88d'><input  type=\"radio\" name=\"input_radio_33\" data-name=\"input_radio_33\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_33_381dd55cc3515c7840a80ed1988bc88d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Malignant Disease\">Malignant Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_36_4fb068752b7b581b37ff2c210aef1d9e'><input  type=\"radio\" name=\"input_radio_36\" data-name=\"input_radio_36\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_36_4fb068752b7b581b37ff2c210aef1d9e' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_36_ca67c9be56960b5ccf298523cd88b7dd'><input  type=\"radio\" name=\"input_radio_36\" data-name=\"input_radio_36\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_36_ca67c9be56960b5ccf298523cd88b7dd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Lung Disease\">Lung Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_34_3287af451bc03201176162b37cdca9eb'><input  type=\"radio\" name=\"input_radio_34\" data-name=\"input_radio_34\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_34_3287af451bc03201176162b37cdca9eb' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_34_5faf0e01417d57e3b7563e41eaa486be'><input  type=\"radio\" name=\"input_radio_34\" data-name=\"input_radio_34\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_34_5faf0e01417d57e3b7563e41eaa486be' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Tuberculosis\">Tuberculosis<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_49_28a69316cfe35658289e243dbe41f395'><input  type=\"radio\" name=\"input_radio_49\" data-name=\"input_radio_49\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_49_28a69316cfe35658289e243dbe41f395' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_49_3b16b06544d135a4d448f467efaf3cb6'><input  type=\"radio\" name=\"input_radio_49\" data-name=\"input_radio_49\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_49_3b16b06544d135a4d448f467efaf3cb6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Mitral Valve Prolapse\">Mitral Valve Prolapse<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_37_fd755597bc4edc244ff4e813317534bc'><input  type=\"radio\" name=\"input_radio_37\" data-name=\"input_radio_37\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_37_fd755597bc4edc244ff4e813317534bc' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_37_820fc1e527c0610e0fc0d50f18316da2'><input  type=\"radio\" name=\"input_radio_37\" data-name=\"input_radio_37\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_37_820fc1e527c0610e0fc0d50f18316da2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Neurological Disease\">Neurological Disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_38_c994d5b9257b612c606071e0e500d933'><input  type=\"radio\" name=\"input_radio_38\" data-name=\"input_radio_38\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_38_c994d5b9257b612c606071e0e500d933' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_38_50b676a417b0cbbb0d40e432069fa0d4'><input  type=\"radio\" name=\"input_radio_38\" data-name=\"input_radio_38\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_38_50b676a417b0cbbb0d40e432069fa0d4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Recent Weight Loss\">Recent Weight Loss<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_39_40b4fe8de82f1c728f5241a04fa29860'><input  type=\"radio\" name=\"input_radio_39\" data-name=\"input_radio_39\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_39_40b4fe8de82f1c728f5241a04fa29860' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_39_c4cc91ded6859212b4dd3e9fec28dc1c'><input  type=\"radio\" name=\"input_radio_39\" data-name=\"input_radio_39\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_39_c4cc91ded6859212b4dd3e9fec28dc1c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Respiratory Problems\">Respiratory Problems<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_40_c59d3a0a86eedd7c309349fd303a224f'><input  type=\"radio\" name=\"input_radio_40\" data-name=\"input_radio_40\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_40_c59d3a0a86eedd7c309349fd303a224f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_40_175fb25e40d1d5ab5fd0f5693bcff9d4'><input  type=\"radio\" name=\"input_radio_40\" data-name=\"input_radio_40\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_40_175fb25e40d1d5ab5fd0f5693bcff9d4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Rheumatic Fever\">Rheumatic Fever<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_41_ae2f8034b57ccc84fdc8c9122587fe03'><input  type=\"radio\" name=\"input_radio_41\" data-name=\"input_radio_41\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_41_ae2f8034b57ccc84fdc8c9122587fe03' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_41_c55ef3defbb0acefad21d0bd8320b7aa'><input  type=\"radio\" name=\"input_radio_41\" data-name=\"input_radio_41\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_41_c55ef3defbb0acefad21d0bd8320b7aa' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Ringing in the Ears\">Ringing in the Ears<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_42_31b3703b665ea04664e442c07bfd05d7'><input  type=\"radio\" name=\"input_radio_42\" data-name=\"input_radio_42\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_42_31b3703b665ea04664e442c07bfd05d7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_42_27a4fbd4bcc9e546a5cfd1adbfe549dc'><input  type=\"radio\" name=\"input_radio_42\" data-name=\"input_radio_42\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_42_27a4fbd4bcc9e546a5cfd1adbfe549dc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Rosacea\">Rosacea<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_44_d1bccab762224000064f48f4cab055bb'><input  type=\"radio\" name=\"input_radio_44\" data-name=\"input_radio_44\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_44_d1bccab762224000064f48f4cab055bb' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_44_2c50b522cc241cca83e817823ef5afc6'><input  type=\"radio\" name=\"input_radio_44\" data-name=\"input_radio_44\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_44_2c50b522cc241cca83e817823ef5afc6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Seizure Disorders\">Seizure Disorders<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_43_381a0e027d009829d920857f549ba021'><input  type=\"radio\" name=\"input_radio_43\" data-name=\"input_radio_43\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_43_381a0e027d009829d920857f549ba021' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_43_e44b4b982307922eafc877384bf4e73f'><input  type=\"radio\" name=\"input_radio_43\" data-name=\"input_radio_43\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_43_e44b4b982307922eafc877384bf4e73f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Stomach Problems\/Ulcers\">Stomach Problems\/Ulcers<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_45_be7a409f2b96a3cee7a1b81d1bd59416'><input  type=\"radio\" name=\"input_radio_45\" data-name=\"input_radio_45\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_45_be7a409f2b96a3cee7a1b81d1bd59416' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_45_28ef4827e77314bbc000f6a2e9ff31ce'><input  type=\"radio\" name=\"input_radio_45\" data-name=\"input_radio_45\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_45_28ef4827e77314bbc000f6a2e9ff31ce' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Stroke\">Stroke<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_46_da7c6e4e0cbb349f729e88f5ac4915c8'><input  type=\"radio\" name=\"input_radio_46\" data-name=\"input_radio_46\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_46_da7c6e4e0cbb349f729e88f5ac4915c8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_46_c432e4f7a8e0f4154174fe310b338ef2'><input  type=\"radio\" name=\"input_radio_46\" data-name=\"input_radio_46\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_46_c432e4f7a8e0f4154174fe310b338ef2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Swollen Ankles\">Swollen Ankles<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_47_30f38e0cad3198ed5f8847980bc62ea6'><input  type=\"radio\" name=\"input_radio_47\" data-name=\"input_radio_47\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_47_30f38e0cad3198ed5f8847980bc62ea6' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_47_f3174fa26882854c94a413f4b12c78db'><input  type=\"radio\" name=\"input_radio_47\" data-name=\"input_radio_47\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_47_f3174fa26882854c94a413f4b12c78db' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Thyroid Problems\">Thyroid Problems<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_48_f4f45af9d779bddaeb4fb8f94b456ed0'><input  type=\"radio\" name=\"input_radio_48\" data-name=\"input_radio_48\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_48_f4f45af9d779bddaeb4fb8f94b456ed0' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_48_40dc918cae8c3ed6a5d3d797f8573702'><input  type=\"radio\" name=\"input_radio_48\" data-name=\"input_radio_48\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_48_40dc918cae8c3ed6a5d3d797f8573702' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Lung Infection, Frequent\">Lung Infection, Frequent<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_35_676da36e0bd2ea2cd9f9cbba500bf45a'><input  type=\"radio\" name=\"input_radio_35\" data-name=\"input_radio_35\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_35_676da36e0bd2ea2cd9f9cbba500bf45a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_35_4505adc96c02ff0f54913f7ce4f54e64'><input  type=\"radio\" name=\"input_radio_35\" data-name=\"input_radio_35\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_35_4505adc96c02ff0f54913f7ce4f54e64' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Have you ever been diagnosed with the following?\">Have you ever been diagnosed with the following?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_e0343401ba4ef29a015c59e3a7b038d2'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pneumothorax (Collapsed Lung)\"  id='checkbox_3_e0343401ba4ef29a015c59e3a7b038d2' aria-label='Pneumothorax (Collapsed Lung)' aria-invalid='false' aria-required=false> <span>Pneumothorax (Collapsed Lung)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_fe82abccd6fbf1f3a5ab500933f20cc7'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pleural effusion (Fluid around the Lungs)\"  id='checkbox_3_fe82abccd6fbf1f3a5ab500933f20cc7' aria-label='Pleural effusion (Fluid around the Lungs)' aria-invalid='false' aria-required=false> <span>Pleural effusion (Fluid around the Lungs)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_a7c9aa9a647d70ff301533a9c292e52e'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Chest Tube Placement\"  id='checkbox_3_a7c9aa9a647d70ff301533a9c292e52e' aria-label='Chest Tube Placement' aria-invalid='false' aria-required=false> <span>Chest Tube Placement<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_1' id='label_ff_3_datetime_1' aria-label=\"If yes, diagnosed date.\">If yes, diagnosed date.<\/label><\/div><div class='ff-el-input--content'><input  aria-label='If yes, diagnosed date. Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_1\" id=\"ff_3_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff_list_buttons'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you have diabetes?\">Do you have diabetes?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_50_199071d00b330fc5706bfbbe9bf25e0f'><input  type=\"radio\" name=\"input_radio_50\" data-name=\"input_radio_50\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_50_199071d00b330fc5706bfbbe9bf25e0f' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_50_ac88b27c33bd72d0c6843c2c5a822f8e'><input  type=\"radio\" name=\"input_radio_50\" data-name=\"input_radio_50\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_50_ac88b27c33bd72d0c6843c2c5a822f8e' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_multi_select' id='label_ff_3_multi_select' aria-label=\"If you have diabetes, how do you manage it?\">If you have diabetes, how do you manage it?<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select[]\" id=\"ff_3_multi_select\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_3_multi_select\"><option value=\"Diet\"  >Diet<\/option><option value=\"Pills\"  >Pills<\/option><option value=\"Insulin\"  >Insulin<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_9' id='label_ff_3_dropdown_9' aria-label=\"Have you ever had any ear problems?\">Have you ever had any ear problems?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_9\" id=\"ff_3_dropdown_9\" class=\"ff-el-form-control\" data-name=\"dropdown_9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_9\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_10' id='label_ff_3_dropdown_10' aria-label=\"Do you have any problems with your ears when you fly?\">Do you have any problems with your ears when you fly?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_10\" id=\"ff_3_dropdown_10\" class=\"ff-el-form-control\" data-name=\"dropdown_10\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_10\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_11' id='label_ff_3_dropdown_11' aria-label=\"Do you have any problems going up and down in an elevator?\">Do you have any problems going up and down in an elevator?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_11\" id=\"ff_3_dropdown_11\" class=\"ff-el-form-control\" data-name=\"dropdown_11\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_11\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_12' id='label_ff_3_dropdown_12' aria-label=\"Do you have any back problems?\">Do you have any back problems?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_12\" id=\"ff_3_dropdown_12\" class=\"ff-el-form-control\" data-name=\"dropdown_12\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_12\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_6' id='label_ff_3_description_6' aria-label=\"Additional Information\">Additional Information<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_6\" name=\"description_6\" id=\"ff_3_description_6\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_6\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_8\" ><h3 class='ff-el-section-title'>6. Covid-19 Information<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_13' id='label_ff_3_dropdown_13' aria-label=\"Have you ever been diagnosed with COVID-19?\">Have you ever been diagnosed with COVID-19?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_13\" id=\"ff_3_dropdown_13\" class=\"ff-el-form-control\" data-name=\"dropdown_13\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_13\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_2' id='label_ff_3_datetime_2' aria-label=\"If yes, when was your most recent diagnosis?\">If yes, when was your most recent diagnosis?<\/label><\/div><div class='ff-el-input--content'><input  aria-label='If yes, when was your most recent diagnosis? Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_2\" id=\"ff_3_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_14' id='label_ff_3_dropdown_14' aria-label=\"Are you currently experiencing any long-term symptoms of COVID-19 (Long COVID)?\">Are you currently experiencing any long-term symptoms of COVID-19 (Long COVID)?<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_14\" id=\"ff_3_dropdown_14\" class=\"ff-el-form-control\" data-name=\"dropdown_14\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\" aria-labelledby=\"label_ff_3_dropdown_14\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Yes<\/option><option value=\"No\"  >No<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"If you selected yes for Long COVID, please check any symptoms that apply:\">If you selected yes for Long COVID, please check any symptoms that apply:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_26146fe61ea8eecb13dfd3da2a71182b'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Fatigue\"  id='checkbox_4_26146fe61ea8eecb13dfd3da2a71182b' aria-label='Fatigue' aria-invalid='false' aria-required=false> <span>Fatigue<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_229cc6ab436cc71b576ca38b82bb32d3'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Difficulty breathing or shortness of breath\"  id='checkbox_4_229cc6ab436cc71b576ca38b82bb32d3' aria-label='Difficulty breathing or shortness of breath' aria-invalid='false' aria-required=false> <span>Difficulty breathing or shortness of breath<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_b9bb31ffe71bc71c745333fe56d32d60'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Cough\"  id='checkbox_4_b9bb31ffe71bc71c745333fe56d32d60' aria-label='Cough' aria-invalid='false' aria-required=false> <span>Cough<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_cb6a416a74d8e6a66a5cd7e880db5ae2'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Chest pain or tightness\"  id='checkbox_4_cb6a416a74d8e6a66a5cd7e880db5ae2' aria-label='Chest pain or tightness' aria-invalid='false' aria-required=false> <span>Chest pain or tightness<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_db0990bb8f33514de6e405815c81373a'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Changes in taste or smell\"  id='checkbox_4_db0990bb8f33514de6e405815c81373a' aria-label='Changes in taste or smell' aria-invalid='false' aria-required=false> <span>Changes in taste or smell<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_72eaa7ebbf2aa46aa6948548eedbeb15'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Difficulty thinking or concentrating (brain fog)\"  id='checkbox_4_72eaa7ebbf2aa46aa6948548eedbeb15' aria-label='Difficulty thinking or concentrating (brain fog)' aria-invalid='false' aria-required=false> <span>Difficulty thinking or concentrating (brain fog)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_df19e957c9b2eabff896047f1d922c5a'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sleep problems\"  id='checkbox_4_df19e957c9b2eabff896047f1d922c5a' aria-label='Sleep problems' aria-invalid='false' aria-required=false> <span>Sleep problems<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_178b34dfb4e98d89eb720252cbe08dd7'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Headache\"  id='checkbox_4_178b34dfb4e98d89eb720252cbe08dd7' aria-label='Headache' aria-invalid='false' aria-required=false> <span>Headache<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_4_a82ead21795a5fcd9f2fca5e0f06255c'><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Joint or muscle pain\"  id='checkbox_4_a82ead21795a5fcd9f2fca5e0f06255c' aria-label='Joint or muscle pain' aria-invalid='false' aria-required=false> <span>Joint or muscle pain<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description_7' id='label_ff_3_description_7' aria-label=\"Other (please specify in the comments box).\">Other (please specify in the comments box).<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_description_7\" name=\"description_7\" id=\"ff_3_description_7\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_7\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_9\" ><h3 class='ff-el-section-title'>Patient Medical Screening Consent<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Please provide your constent for the following:\">Please provide your constent for the following:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_8b0941e287dda8c5bcd773a8c241e781'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I have answered the medical screening questions truthfully and accurately.\"  id='checkbox_5_8b0941e287dda8c5bcd773a8c241e781' aria-label='I have answered the medical screening questions truthfully and accurately.' aria-invalid='false' aria-required=true> <span>I have answered the medical screening questions truthfully and accurately.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_8023fdaa48b65c8e9a1405dda4ef48cc'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I authorize the release of my medical information from this practice to any healthcare provider involved in my treatment.\"  id='checkbox_5_8023fdaa48b65c8e9a1405dda4ef48cc' aria-label='I authorize the release of my medical information from this practice to any healthcare provider involved in my treatment.' aria-invalid='false' aria-required=true> <span>I authorize the release of my medical information from this practice to any healthcare provider involved in my treatment.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_688d4d5c5619d351d6da2c7970ba7867'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I understand that I am responsible for keeping my medical information up-to-date, including changes in diagnoses, medications, contact details (mine and my doctor&#039;s), and insurance information.\"  id='checkbox_5_688d4d5c5619d351d6da2c7970ba7867' aria-label='I understand that I am responsible for keeping my medical information up-to-date, including changes in diagnoses, medications, contact details (mine and my doctor&#039;s), and insurance information.' aria-invalid='false' aria-required=true> <span>I understand that I am responsible for keeping my medical information up-to-date, including changes in diagnoses, medications, contact details (mine and my doctor's), and insurance information.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5_1b1bce6c080753d55bd5fc3f8ef32aa3'><input  type=\"checkbox\" name=\"checkbox_5[]\" data-name=\"checkbox_5\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I agree to be financially responsible for all services provided to me or my dependents.\"  id='checkbox_5_1b1bce6c080753d55bd5fc3f8ef32aa3' aria-label='I agree to be financially responsible for all services provided to me or my dependents.' aria-invalid='false' aria-required=true> <span>I agree to be financially responsible for all services provided to me or my dependents.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_10\" ><h3 class='ff-el-section-title'>Informed Consent<\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\">Hyperbaric PHP offers mild hyperbaric therapy treatments. While we believe this therapy may be beneficial for a variety of conditions, it's important to understand:<\/p>\n<div class=\"jseditor-contract-line jseditor-contract-line-paragraph-font margin-bottom-05 jseditor-list-item-UL-depth-1 jseditor-counter-reset-depth-1 jseditor-depth-1\" data-depth=\"1\" data-list-item=\"UL\"><strong>We are not a substitute for medical care.<\/strong> Hyperbaric therapy is not a guaranteed cure and should not replace treatments prescribed by your doctor.<\/div>\n<div class=\"jseditor-contract-line jseditor-contract-line-paragraph-font margin-bottom-05 jseditor-list-item-UL-depth-1 jseditor-counter-reset-depth-1 jseditor-depth-1\" data-depth=\"1\" data-list-item=\"UL\"><strong>Individual results may vary.<\/strong> The effectiveness of hyperbaric therapy can differ from person to person.<\/div>\n<div class=\"jseditor-contract-line jseditor-contract-line-paragraph-font margin-bottom-05 jseditor-list-item-UL-depth-1 jseditor-counter-reset-depth-1 jseditor-depth-1\" data-depth=\"1\" data-list-item=\"UL\"><strong>We are not medical professionals and do not accept insurance.<\/strong><\/div>\n<p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\"><strong>Disclaimer:<\/strong> We recommend consulting with your doctor to determine if Hyperbaric therapy is right for you.<\/p><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Please provide your consent for the following:\">Please provide your consent for the following:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_fc057da8f86066dc5ecd36cc062fff18'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I have read and understand the information provided about mild Hyperbaric therapy at Hyperbaric PHP.\"  id='checkbox_6_fc057da8f86066dc5ecd36cc062fff18' aria-label='I have read and understand the information provided about mild Hyperbaric therapy at Hyperbaric PHP.' aria-invalid='false' aria-required=true> <span>I have read and understand the information provided about mild Hyperbaric therapy at Hyperbaric PHP.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_28a3b7c8d02b4eab22b9a4810d3a81a5'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I agree to receive mild Hyperbaric therapy treatments at Hyperbaric PHP.\"  id='checkbox_6_28a3b7c8d02b4eab22b9a4810d3a81a5' aria-label='I agree to receive mild Hyperbaric therapy treatments at Hyperbaric PHP.' aria-invalid='false' aria-required=true> <span>I agree to receive mild Hyperbaric therapy treatments at Hyperbaric PHP.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_afd850cfab42b178c097766a43f6eb42'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I agree to release Hyperbaric PHP and its staff from any claims or liabilities arising from the use of mild Hyperbaric therapy services provided by Hyperbaric PHP.\"  id='checkbox_6_afd850cfab42b178c097766a43f6eb42' aria-label='I agree to release Hyperbaric PHP and its staff from any claims or liabilities arising from the use of mild Hyperbaric therapy services provided by Hyperbaric PHP.' aria-invalid='false' aria-required=true> <span>I agree to release Hyperbaric PHP and its staff from any claims or liabilities arising from the use of mild Hyperbaric therapy services provided by Hyperbaric PHP.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_1f1793723f931341c7e338e3fb906258'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"In the unlikely event of a disagreement, you agree to settle it through arbitration with the Better Business Bureau of Metropolitan Atlanta.\"  id='checkbox_6_1f1793723f931341c7e338e3fb906258' aria-label='In the unlikely event of a disagreement, you agree to settle it through arbitration with the Better Business Bureau of Metropolitan Atlanta.' aria-invalid='false' aria-required=true> <span>In the unlikely event of a disagreement, you agree to settle it through arbitration with the Better Business Bureau of Metropolitan Atlanta.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6_86a16a158d9180d6d7ad06fee5ff0e9a'><input  type=\"checkbox\" name=\"checkbox_6[]\" data-name=\"checkbox_6\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I agree to be financially responsible for all services provided to me or my dependents.\"  id='checkbox_6_86a16a158d9180d6d7ad06fee5ff0e9a' aria-label='I agree to be financially responsible for all services provided to me or my dependents.' aria-invalid='false' aria-required=true> <span>I agree to be financially responsible for all services provided to me or my dependents.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_11\" ><h3 class='ff-el-section-title'>Communication Preferences<\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\" data-pm-slice=\"1 1 []\">We'd love to keep you informed about your health and appointments at Hyperbaric PHP. Please uncheck any boxes below if you don't wish to receive these communications.<\/p><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Please provide your consent for the following:\">Please provide your consent for the following:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_165422efc4045df51aa30fe627dca862'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I authorize Hyperbaric PHP to contact me about appointment reminders &amp; missed appointment notifications (via phone call, text message, or email).\"  id='checkbox_7_165422efc4045df51aa30fe627dca862' aria-label='I authorize Hyperbaric PHP to contact me about appointment reminders &amp; missed appointment notifications (via phone call, text message, or email).' aria-invalid='false' aria-required=true> <span>I authorize Hyperbaric PHP to contact me about appointment reminders &amp; missed appointment notifications (via phone call, text message, or email).<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_7_493a52915ca7887388bddb421ef839b2'><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I authorize Hyperbaric PHP to leave a message on my voicemail or answering machine.\"  id='checkbox_7_493a52915ca7887388bddb421ef839b2' aria-label='I authorize Hyperbaric PHP to leave a message on my voicemail or answering machine.' aria-invalid='false' aria-required=true> <span>I authorize Hyperbaric PHP to leave a message on my voicemail or answering machine.<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_12\" ><h3 class='ff-el-section-title'>Share your story<\/h3><div class='ff-section_break_desk'><p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\" data-pm-slice=\"1 1 []\">We'd love to showcase the positive impact we have on our clients! <strong>With your permission,<\/strong> we may use photos, videos, and written testimonials you provide to share on our website, in our center, or at events. These stories can inspire others on their health journeys. Please uncheck if you do not wish to share your story.<\/p>\n<p class=\"jseditor-contract-line jseditor-contract-line-paragraph-font jseditor-contract-line-unstyled jseditor-list-item-counter-reset\" data-depth=\"0\">\u00a0<\/p><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Please provide your consent for the following:\">Please provide your consent for the following:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_47d875cfb3a7d0f69dcfbbea3a0e2b77'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I consent to the use of photos and\/or videos of me and\/or my child.\"  id='checkbox_8_47d875cfb3a7d0f69dcfbbea3a0e2b77' aria-label='I consent to the use of photos and\/or videos of me and\/or my child.' aria-invalid='false' aria-required=false> <span>I consent to the use of photos and\/or videos of me and\/or my child.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8_b9ac5f5cbf77df101835edbfc02a508d'><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I consent to the use of all or part of my written testimonial, including my name and\/or my child&#039;s name.\"  id='checkbox_8_b9ac5f5cbf77df101835edbfc02a508d' aria-label='I consent to the use of all or part of my written testimonial, including my name and\/or my child&#039;s name.' aria-invalid='false' aria-required=false> <span>I consent to the use of all or part of my written testimonial, including my name and\/or my child's name.<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='By signing below, I acknowledge that I have read and understand the information provided on this form, including the potential benefits and risks of Hyperbaric Oxygen Therapy.' class='ff-el-form-check-label ff_tc_label' for='gdpr-agreement_fa19e50dad4ef4787550f5a7654ecd05'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"gdpr-agreement\" class=\"ff-el-form-check-input ff_gdpr_field\" data-name=\"gdpr-agreement\" id=\"gdpr-agreement_fa19e50dad4ef4787550f5a7654ecd05\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>By signing below, I acknowledge that I have read and understand the information provided on this form, including the potential benefits and risks of Hyperbaric Oxygen Therapy.<\/div><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_mask_5' id='label_ff_3_input_mask_5' aria-label=\"Mask Input\">Mask Input<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" 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