{"id":96,"date":"2023-02-07T02:23:59","date_gmt":"2023-02-07T02:23:59","guid":{"rendered":"http:\/\/stage.mvsj.com\/stage\/?page_id=96"},"modified":"2023-05-31T00:18:52","modified_gmt":"2023-05-31T00:18:52","slug":"patient-intake","status":"publish","type":"page","link":"https:\/\/stage.mvsj.com\/stage\/patient-forms\/patient-intake\/","title":{"rendered":"Patient Intake"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Patient Data and Current Medical History<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/stage\/wp-json\/wp\/v2\/pages\/96' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_1\"  class=\"gfield gfield--type-html gfield--width-three-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\"><img decoding=\"async\" src=\"http:\/\/stage.mvsj.com\/stage\/wp-content\/uploads\/MVSJ-CMYK-ShortHorizontal-433w.webp\"\/><\/div><div id=\"field_2_2\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\"><label class='gfield_label gform-field-label' for='input_2_2' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_2_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_2' class='gform_hidden' value='https:\/\/stage.mvsj.com\/stage\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_3\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Patient Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_2_3'>\n                            \n                            <span id='input_2_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_2_3_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.4' id='input_2_3_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_2_3_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_3_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.8' id='input_2_3_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><fieldset id=\"field_2_4\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_2_4_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_4_1' id='input_2_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_2_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_4_2' id='input_2_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_2_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_4_3' id='input_2_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_4_4_container' >\n                                        <input type='text' name='input_4.4' id='input_2_4_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_4_4' id='input_2_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_2_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_4_5' id='input_2_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_2_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_5\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><label class='gfield_label gform-field-label' for='input_2_5' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label' for='input_2_7' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><label class='gfield_label gform-field-label' for='input_2_6' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_9\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Would you prefer appointment reminders via text?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_9'><div class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Yes'  id='choice_2_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='No'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_11\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\"><label class='gfield_label gform-field-label' for='input_2_11' >Preferred Contact Numer<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_2_11' class='large gfield_select'  aria-describedby=\"gfield_description_2_11\"   aria-invalid=\"false\" ><option value='Home Phone' >Home Phone<\/option><option value='Cell Phone' >Cell Phone<\/option><option value='Work Phone' >Work Phone<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_11'>Select your preferred contact phone<\/div><\/div><div id=\"field_2_12\"  class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\"><label class='gfield_label gform-field-label' for='input_2_12' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_2_12' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_13\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><label class='gfield_label gform-field-label' for='input_2_13' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_2_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_13' class='gform_hidden' value='https:\/\/stage.mvsj.com\/stage\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_15\"  class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><label class='gfield_label gform-field-label' for='input_2_15' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_15' id='input_2_15' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_18\"  class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\"><label class='gfield_label gform-field-label' for='input_2_18' >Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_2_18' class='large gfield_select'  aria-describedby=\"gfield_description_2_18\"   aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_18'>Please provide sex assigned at birth.<\/div><\/div><div id=\"field_2_20\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label gform-field-label' for='input_2_20' >Referred by<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_21\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label gform-field-label' for='input_2_21' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_22\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label gform-field-label' for='input_2_22' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_24\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Emergency Contact Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_24'>\n                            \n                            <span id='input_2_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_2_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_2_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_25\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label gform-field-label' for='input_2_25' >Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_26\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><label class='gfield_label gform-field-label' for='input_2_26' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><h3 class=\"gsection_title\">Patient Medical History<\/h3><\/div><div id=\"field_2_27\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label gform-field-label' for='input_2_27' >What is your complaint<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_28\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label gform-field-label' for='input_2_28' >How long have you had this problem<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_29\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label gform-field-label' for='input_2_29' >Have you had any previous care or seen any other provider(s) for this problem\/Are you seeing any doctors?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_30\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><label class='gfield_label gform-field-label' for='input_2_30' >What are you doing for it now?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_2_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_31\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\"><label class='gfield_label gform-field-label' for='input_2_31' >Is it working?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_32\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label gform-field-label' for='input_2_32' >Have you noticed any changes in your daily activities due to the problem or pain? (Dressing, Cooking, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_33\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\"><label class='gfield_label gform-field-label' for='input_2_33' >Are there any other related or unrelated systems?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_34\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><legend class='gfield_label gform-field-label'  >Overall Stress Level (0=Low \/ 10=High)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_34'>\n\t\t\t<div class='gchoice gchoice_2_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='0'  id='choice_2_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='1'  id='choice_2_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='2'  id='choice_2_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_2' id='label_2_34_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='3'  id='choice_2_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_3' id='label_2_34_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='4'  id='choice_2_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_4' id='label_2_34_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='5'  id='choice_2_34_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_5' id='label_2_34_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='6'  id='choice_2_34_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_6' id='label_2_34_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='7'  id='choice_2_34_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_7' id='label_2_34_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='8'  id='choice_2_34_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_8' id='label_2_34_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='9'  id='choice_2_34_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_9' id='label_2_34_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='10'  id='choice_2_34_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_10' id='label_2_34_10' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_35\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><legend class='gfield_label gform-field-label'  >What is your sleeping habit?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_35'>\n\t\t\t<div class='gchoice gchoice_2_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Back'  id='choice_2_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_0' id='label_2_35_0' class='gform-field-label gform-field-label--type-inline'>On Back<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Side'  id='choice_2_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_1' id='label_2_35_1' class='gform-field-label gform-field-label--type-inline'>On Side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Stomach'  id='choice_2_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_2' id='label_2_35_2' class='gform-field-label gform-field-label--type-inline'>On Stomach<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_36\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label gform-field-label' for='input_2_36' >When was the last time you really felt good?<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_37\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><h3 class=\"gsection_title\">PATIENT HISTORY \/ REVIEW OF SYMPTOMS<\/h3><div class='gsection_description' id='gfield_description_2_37'>Please tell us if YOU or a member of YOUR IMMEDIATE FAMILY have had any of the following.<\/div><\/div><div id=\"field_2_50\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><h3>SYMPTOMS<\/h3><\/div><div id=\"field_2_38\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_38\"><h3>You<\/h3><\/div><div id=\"field_2_39\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><h3>FAMILY MEMBER<\/h3><\/div><div id=\"field_2_51\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><strong>Back Pain \/ Leg Pain<\/strong><\/div><fieldset id=\"field_2_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><legend class='gfield_label gform-field-label'  >Back Pain \/ Leg Pain(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_41'>\n\t\t\t<div class='gchoice gchoice_2_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_2_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_2_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_40\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_40\"><legend class='gfield_label gform-field-label'  >Back Pain \/ Leg Pain(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_40'>\n\t\t\t<div class='gchoice gchoice_2_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_2_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_0' id='label_2_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_2_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_1' id='label_2_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_52\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><strong>Neck Pain \/ Arm Pain<\/strong><\/div><fieldset id=\"field_2_42\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_42\"><legend class='gfield_label gform-field-label'  >Neck Pain \/ Arm Pain(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_42'>\n\t\t\t<div class='gchoice gchoice_2_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_2_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_0' id='label_2_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_2_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><legend class='gfield_label gform-field-label'  >Neck Pain \/ Arm Pain(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_53\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><strong>Cancer<\/strong><\/div><fieldset id=\"field_2_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><legend class='gfield_label gform-field-label'  >Cancer(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_44'>\n\t\t\t<div class='gchoice gchoice_2_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_2_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_0' id='label_2_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_2_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><legend class='gfield_label gform-field-label'  >Cancer(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_54\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><strong>Diabetes<\/strong><\/div><fieldset id=\"field_2_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><legend class='gfield_label gform-field-label'  >Diabetes(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_46'>\n\t\t\t<div class='gchoice gchoice_2_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_2_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_0' id='label_2_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_2_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><legend class='gfield_label gform-field-label'  >Diabetes(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_47'>\n\t\t\t<div class='gchoice gchoice_2_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_2_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_47_0' id='label_2_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_2_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_55\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><strong>Neurological Disease \/ Headaches \/ Seizures<\/strong><\/div><fieldset id=\"field_2_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><legend class='gfield_label gform-field-label'  >Neurological Disease \/ Headaches \/ Seizures(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_48'>\n\t\t\t<div class='gchoice gchoice_2_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_2_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_2_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_49\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><legend class='gfield_label gform-field-label'  >Neurological Disease \/ Headaches \/ Seizures(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_49'>\n\t\t\t<div class='gchoice gchoice_2_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_2_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_0' id='label_2_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_2_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_1' id='label_2_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_56\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\"><strong>Heart \/ Circulatory Problems<\/strong><\/div><fieldset id=\"field_2_58\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_58\"><legend class='gfield_label gform-field-label'  >Heart \/ Circulatory Problems(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_58'>\n\t\t\t<div class='gchoice gchoice_2_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_2_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_0' id='label_2_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_2_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_59\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_59\"><legend class='gfield_label gform-field-label'  >Heart \/ Circulatory Problems(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_59'>\n\t\t\t<div class='gchoice gchoice_2_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_2_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_2_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_57\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><strong>High Blood Pressure<\/strong><\/div><fieldset id=\"field_2_61\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><legend class='gfield_label gform-field-label'  >High Blood Pressure(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_61'>\n\t\t\t<div class='gchoice gchoice_2_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_2_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_0' id='label_2_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_2_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_1' id='label_2_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_62\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><legend class='gfield_label gform-field-label'  >High Blood Pressure(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_62'>\n\t\t\t<div class='gchoice gchoice_2_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_2_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_2_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_60\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><strong>Stomach or Bowel Problems<\/strong><\/div><fieldset id=\"field_2_64\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><legend class='gfield_label gform-field-label'  >Stomach or Bowel Problems(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_64'>\n\t\t\t<div class='gchoice gchoice_2_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_2_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_2_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_65\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><legend class='gfield_label gform-field-label'  >Stomach or Bowel Problems(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_65'>\n\t\t\t<div class='gchoice gchoice_2_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_2_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_65_0' id='label_2_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_2_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_63\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><strong>Broken Bones<\/strong><\/div><fieldset id=\"field_2_67\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_67\"><legend class='gfield_label gform-field-label'  >Broken Bones(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_67'>\n\t\t\t<div class='gchoice gchoice_2_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_2_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_67_0' id='label_2_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_2_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_67_1' id='label_2_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_68\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_68\"><legend class='gfield_label gform-field-label'  >Broken Bones(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_68'>\n\t\t\t<div class='gchoice gchoice_2_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_2_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_68_0' id='label_2_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_2_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_68_1' id='label_2_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_66\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_66\"><strong>Skin Disease<\/strong><\/div><fieldset id=\"field_2_70\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_70\"><legend class='gfield_label gform-field-label'  >Skin Disease(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_70'>\n\t\t\t<div class='gchoice gchoice_2_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_2_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_70_0' id='label_2_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_2_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_70_1' id='label_2_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_71\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_71\"><legend class='gfield_label gform-field-label'  >Skin Disease(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_71'>\n\t\t\t<div class='gchoice gchoice_2_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_2_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_71_0' id='label_2_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_2_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_71_1' id='label_2_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_69\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_69\"><strong>Prostate Disease \/ Hormone Therapy<\/strong><\/div><fieldset id=\"field_2_73\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_73\"><legend class='gfield_label gform-field-label'  >Prostate Disease \/ Hormone Therapy(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_73'>\n\t\t\t<div class='gchoice gchoice_2_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_2_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_73_0' id='label_2_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_2_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_73_1' id='label_2_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_74\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_74\"><legend class='gfield_label gform-field-label'  >Prostate Disease \/ Hormone Therapy(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_74'>\n\t\t\t<div class='gchoice gchoice_2_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_2_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_74_0' id='label_2_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_2_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_74_1' id='label_2_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_72\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\"><strong>Depression, Anxiety, etc.<\/strong><\/div><fieldset id=\"field_2_76\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_76\"><legend class='gfield_label gform-field-label'  >Depression, Anxiety, etc.(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_76'>\n\t\t\t<div class='gchoice gchoice_2_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_2_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_0' id='label_2_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_2_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_1' id='label_2_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_77\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_77\"><legend class='gfield_label gform-field-label'  >Depression, Anxiety, etc.(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_77'>\n\t\t\t<div class='gchoice gchoice_2_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_2_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_0' id='label_2_77_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_2_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_1' id='label_2_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_75\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\"><strong>Painful or Irregular Menstrual Cycles<\/strong><\/div><fieldset id=\"field_2_79\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_79\"><legend class='gfield_label gform-field-label'  >Painful or Irregular Menstrual Cycles(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_79'>\n\t\t\t<div class='gchoice gchoice_2_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_2_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_79_0' id='label_2_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_2_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_79_1' id='label_2_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_80\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_80\"><legend class='gfield_label gform-field-label'  >Painful or Irregular Menstrual Cycles(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_80'>\n\t\t\t<div class='gchoice gchoice_2_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_2_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_2_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_81\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_81\"><strong>Tendonitis<\/strong><\/div><fieldset id=\"field_2_82\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_82\"><legend class='gfield_label gform-field-label'  >Tendonitis(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_82'>\n\t\t\t<div class='gchoice gchoice_2_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_2_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_0' id='label_2_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_2_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_1' id='label_2_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_83\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_83\"><legend class='gfield_label gform-field-label'  >Tendonitis(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_83'>\n\t\t\t<div class='gchoice gchoice_2_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_2_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_83_0' id='label_2_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_2_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_83_1' id='label_2_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_78\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\"><strong>Exercise on a Regular Basis<\/strong><\/div><fieldset id=\"field_2_85\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_85\"><legend class='gfield_label gform-field-label'  >Exercise on a Regular Basis(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_85'>\n\t\t\t<div class='gchoice gchoice_2_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_2_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_0' id='label_2_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_2_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_1' id='label_2_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_86\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_86\"><legend class='gfield_label gform-field-label'  >Exercise on a Regular Basis(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_86'>\n\t\t\t<div class='gchoice gchoice_2_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_2_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_86_0' id='label_2_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_2_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_86_1' id='label_2_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_84\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\"><strong>Motor Vehicle Accident or Other Injuries<\/strong><\/div><fieldset id=\"field_2_88\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_88\"><legend class='gfield_label gform-field-label'  >Motor Vehicle Accident or Other Injuries(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_88'>\n\t\t\t<div class='gchoice gchoice_2_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_2_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_88_0' id='label_2_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_2_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_88_1' id='label_2_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_89\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_89\"><legend class='gfield_label gform-field-label'  >Motor Vehicle Accident or Other Injuries(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_89'>\n\t\t\t<div class='gchoice gchoice_2_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Yes'  id='choice_2_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_89_0' id='label_2_89_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='No'  id='choice_2_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_89_1' id='label_2_89_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_87\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_87\"><strong>Alcohol \/ Nicotine Use<\/strong><\/div><fieldset id=\"field_2_91\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_91\"><legend class='gfield_label gform-field-label'  >Alcohol \/ Nicotine Use(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_91'>\n\t\t\t<div class='gchoice gchoice_2_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_2_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_0' id='label_2_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_2_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_1' id='label_2_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_92\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_92\"><legend class='gfield_label gform-field-label'  >Alcohol \/ Nicotine Use(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_92'>\n\t\t\t<div class='gchoice gchoice_2_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Yes'  id='choice_2_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_0' id='label_2_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='No'  id='choice_2_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_1' id='label_2_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_90\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_90\"><strong>Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough<\/strong><\/div><fieldset id=\"field_2_94\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_94\"><legend class='gfield_label gform-field-label'  >Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_94'>\n\t\t\t<div class='gchoice gchoice_2_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes'  id='choice_2_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_94_0' id='label_2_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No'  id='choice_2_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_94_1' id='label_2_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_95\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_95\"><legend class='gfield_label gform-field-label'  >Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_95'>\n\t\t\t<div class='gchoice gchoice_2_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Yes'  id='choice_2_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_0' id='label_2_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='No'  id='choice_2_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_93\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_93\"><strong>Surgeries<\/strong><\/div><fieldset id=\"field_2_97\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_97\"><legend class='gfield_label gform-field-label'  >Surgeries(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_97'>\n\t\t\t<div class='gchoice gchoice_2_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Yes'  id='choice_2_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_0' id='label_2_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='No'  id='choice_2_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_98\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_98\"><legend class='gfield_label gform-field-label'  >Surgeries(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_98'>\n\t\t\t<div class='gchoice gchoice_2_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_2_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_0' id='label_2_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_2_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_1' id='label_2_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_96\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_96\"><strong>Chiropractic Treatment Before<\/strong><\/div><fieldset id=\"field_2_100\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_100\"><legend class='gfield_label gform-field-label'  >Chiropractic Treatment Before(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_100'>\n\t\t\t<div class='gchoice gchoice_2_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_2_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_0' id='label_2_100_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_2_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_1' id='label_2_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_101\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_101\"><legend class='gfield_label gform-field-label'  >Chiropractic Treatment Before(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_101'>\n\t\t\t<div class='gchoice gchoice_2_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_2_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_0' id='label_2_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_2_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_1' id='label_2_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_99\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_99\"><strong>Unintended Weight Gain \/ Loss<\/strong><\/div><fieldset id=\"field_2_103\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_103\"><legend class='gfield_label gform-field-label'  >Unintended Weight Gain \/ Loss(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_103'>\n\t\t\t<div class='gchoice gchoice_2_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_2_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_0' id='label_2_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_2_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_1' id='label_2_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_104\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_104\"><legend class='gfield_label gform-field-label'  >Unintended Weight Gain \/ Loss(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_104'>\n\t\t\t<div class='gchoice gchoice_2_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_2_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_0' id='label_2_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_2_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_1' id='label_2_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_102\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_102\"><strong>Recent International Travel<\/strong><\/div><fieldset id=\"field_2_105\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_105\"><legend class='gfield_label gform-field-label'  >Recent International Travel(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_105'>\n\t\t\t<div class='gchoice gchoice_2_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_2_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_105_0' id='label_2_105_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_2_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_105_1' id='label_2_105_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_106\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_106\"><legend class='gfield_label gform-field-label'  >Recent International Travel(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_106'>\n\t\t\t<div class='gchoice gchoice_2_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='Yes'  id='choice_2_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_106_0' id='label_2_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='No'  id='choice_2_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_106_1' id='label_2_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_107\"  class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_107\"><legend class='gfield_label gform-field-label'  >LIST OF MEDICATIONS<\/legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell1 gform-grid-col' ><input aria-invalid='false'   aria-label='LIST OF MEDICATIONS, Row 1' data-aria-label-template='LIST OF MEDICATIONS, Row {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' 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gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='1' id='gform_wrapper_2' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Patient Data and Current Medical History<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/stage\/wp-json\/wp\/v2\/pages\/96' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_1\"  class=\"gfield gfield--type-html gfield--width-three-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\"><img decoding=\"async\" src=\"http:\/\/stage.mvsj.com\/stage\/wp-content\/uploads\/MVSJ-CMYK-ShortHorizontal-433w.webp\"\/><\/div><div id=\"field_2_2\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\"><label class='gfield_label gform-field-label' for='input_2_2' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_2_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_2' class='gform_hidden' value='https:\/\/stage.mvsj.com\/stage\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_3\"  class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Patient Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_2_3'>\n                            \n                            <span id='input_2_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_2_3_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.4' id='input_2_3_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_2_3_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_2_3_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.8' id='input_2_3_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_3_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                <\/span>\n                        <\/div><\/fieldset><fieldset id=\"field_2_4\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_2_4_1' value=''    aria-required='false'    \/>\n                                        <label for='input_2_4_1' id='input_2_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_2_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_4_2' id='input_2_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_2_4_3' value=''    aria-required='false'    \/>\n                                    <label for='input_2_4_3' id='input_2_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_4_4_container' >\n                                        <input type='text' name='input_4.4' id='input_2_4_4' value=''      aria-required='false'    \/>\n                                        <label for='input_2_4_4' id='input_2_4_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_2_4_5' value=''    aria-required='false'    \/>\n                                    <label for='input_2_4_5' id='input_2_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_2_4_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_5\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><label class='gfield_label gform-field-label' for='input_2_5' >Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label' for='input_2_7' >Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_2_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><label class='gfield_label gform-field-label' for='input_2_6' >Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_9\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Would you prefer appointment reminders via text?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_9'><div class='gchoice gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='Yes'  id='choice_2_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='No'  id='choice_2_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_11\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_11\"><label class='gfield_label gform-field-label' for='input_2_11' >Preferred Contact Numer<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_2_11' class='large gfield_select'  aria-describedby=\"gfield_description_2_11\"   aria-invalid=\"false\" ><option value='Home Phone' >Home Phone<\/option><option value='Cell Phone' >Cell Phone<\/option><option value='Work Phone' >Work Phone<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_11'>Select your preferred contact phone<\/div><\/div><div id=\"field_2_12\"  class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\"><label class='gfield_label gform-field-label' for='input_2_12' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_2_12' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_13\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><label class='gfield_label gform-field-label' for='input_2_13' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_2_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_13' class='gform_hidden' value='https:\/\/stage.mvsj.com\/stage\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_15\"  class=\"gfield gfield--type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><label class='gfield_label gform-field-label' for='input_2_15' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_15' id='input_2_15' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_18\"  class=\"gfield gfield--type-select gfield--width-third field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\"><label class='gfield_label gform-field-label' for='input_2_18' >Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_2_18' class='large gfield_select'  aria-describedby=\"gfield_description_2_18\"   aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_18'>Please provide sex assigned at birth.<\/div><\/div><div id=\"field_2_20\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label gform-field-label' for='input_2_20' >Referred by<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_21\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label gform-field-label' for='input_2_21' >Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_22\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label gform-field-label' for='input_2_22' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_24\"  class=\"gfield gfield--type-name gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Emergency Contact Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_24'>\n                            \n                            <span id='input_2_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_2_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_2_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_25\"  class=\"gfield gfield--type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label gform-field-label' for='input_2_25' >Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_26\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><label class='gfield_label gform-field-label' for='input_2_26' >Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><h3 class=\"gsection_title\">Patient Medical History<\/h3><\/div><div id=\"field_2_27\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label gform-field-label' for='input_2_27' >What is your complaint<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_28\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label gform-field-label' for='input_2_28' >How long have you had this problem<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_29\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label gform-field-label' for='input_2_29' >Have you had any previous care or seen any other provider(s) for this problem\/Are you seeing any doctors?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_30\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><label class='gfield_label gform-field-label' for='input_2_30' >What are you doing for it now?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_2_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_31\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\"><label class='gfield_label gform-field-label' for='input_2_31' >Is it working?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_32\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label gform-field-label' for='input_2_32' >Have you noticed any changes in your daily activities due to the problem or pain? (Dressing, Cooking, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_33\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\"><label class='gfield_label gform-field-label' for='input_2_33' >Are there any other related or unrelated systems?<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_34\"  class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><legend class='gfield_label gform-field-label'  >Overall Stress Level (0=Low \/ 10=High)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_34'>\n\t\t\t<div class='gchoice gchoice_2_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='0'  id='choice_2_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>0<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='1'  id='choice_2_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='2'  id='choice_2_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_2' id='label_2_34_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='3'  id='choice_2_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_3' id='label_2_34_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='4'  id='choice_2_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_4' id='label_2_34_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='5'  id='choice_2_34_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_5' id='label_2_34_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='6'  id='choice_2_34_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_6' id='label_2_34_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='7'  id='choice_2_34_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_7' id='label_2_34_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='8'  id='choice_2_34_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_8' id='label_2_34_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='9'  id='choice_2_34_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_9' id='label_2_34_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='10'  id='choice_2_34_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_10' id='label_2_34_10' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_35\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><legend class='gfield_label gform-field-label'  >What is your sleeping habit?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_35'>\n\t\t\t<div class='gchoice gchoice_2_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Back'  id='choice_2_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_0' id='label_2_35_0' class='gform-field-label gform-field-label--type-inline'>On Back<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Side'  id='choice_2_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_1' id='label_2_35_1' class='gform-field-label gform-field-label--type-inline'>On Side<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_35_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='On Stomach'  id='choice_2_35_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_35_2' id='label_2_35_2' class='gform-field-label gform-field-label--type-inline'>On Stomach<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_36\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label gform-field-label' for='input_2_36' >When was the last time you really felt good?<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_37\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><h3 class=\"gsection_title\">PATIENT HISTORY \/ REVIEW OF SYMPTOMS<\/h3><div class='gsection_description' id='gfield_description_2_37'>Please tell us if YOU or a member of YOUR IMMEDIATE FAMILY have had any of the following.<\/div><\/div><div id=\"field_2_50\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><h3>SYMPTOMS<\/h3><\/div><div id=\"field_2_38\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_38\"><h3>You<\/h3><\/div><div id=\"field_2_39\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><h3>FAMILY MEMBER<\/h3><\/div><div id=\"field_2_51\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><strong>Back Pain \/ Leg Pain<\/strong><\/div><fieldset id=\"field_2_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><legend class='gfield_label gform-field-label'  >Back Pain \/ Leg Pain(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_41'>\n\t\t\t<div class='gchoice gchoice_2_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Yes'  id='choice_2_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='No'  id='choice_2_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_40\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_40\"><legend class='gfield_label gform-field-label'  >Back Pain \/ Leg Pain(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_40'>\n\t\t\t<div class='gchoice gchoice_2_40_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='Yes'  id='choice_2_40_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_0' id='label_2_40_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_40_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_40' type='radio' value='No'  id='choice_2_40_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_40_1' id='label_2_40_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_52\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><strong>Neck Pain \/ Arm Pain<\/strong><\/div><fieldset id=\"field_2_42\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_42\"><legend class='gfield_label gform-field-label'  >Neck Pain \/ Arm Pain(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_42'>\n\t\t\t<div class='gchoice gchoice_2_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Yes'  id='choice_2_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_0' id='label_2_42_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='No'  id='choice_2_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><legend class='gfield_label gform-field-label'  >Neck Pain \/ Arm Pain(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_53\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><strong>Cancer<\/strong><\/div><fieldset id=\"field_2_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><legend class='gfield_label gform-field-label'  >Cancer(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_44'>\n\t\t\t<div class='gchoice gchoice_2_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Yes'  id='choice_2_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_0' id='label_2_44_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_2_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><legend class='gfield_label gform-field-label'  >Cancer(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_54\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><strong>Diabetes<\/strong><\/div><fieldset id=\"field_2_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><legend class='gfield_label gform-field-label'  >Diabetes(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_46'>\n\t\t\t<div class='gchoice gchoice_2_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='Yes'  id='choice_2_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_0' id='label_2_46_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_2_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_47\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><legend class='gfield_label gform-field-label'  >Diabetes(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_47'>\n\t\t\t<div class='gchoice gchoice_2_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_2_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_47_0' id='label_2_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_2_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_47_1' id='label_2_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_55\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><strong>Neurological Disease \/ Headaches \/ Seizures<\/strong><\/div><fieldset id=\"field_2_48\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><legend class='gfield_label gform-field-label'  >Neurological Disease \/ Headaches \/ Seizures(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_48'>\n\t\t\t<div class='gchoice gchoice_2_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='Yes'  id='choice_2_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_2_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_49\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><legend class='gfield_label gform-field-label'  >Neurological Disease \/ Headaches \/ Seizures(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_49'>\n\t\t\t<div class='gchoice gchoice_2_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_2_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_0' id='label_2_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_2_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_1' id='label_2_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_56\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\"><strong>Heart \/ Circulatory Problems<\/strong><\/div><fieldset id=\"field_2_58\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_58\"><legend class='gfield_label gform-field-label'  >Heart \/ Circulatory Problems(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_58'>\n\t\t\t<div class='gchoice gchoice_2_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Yes'  id='choice_2_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_0' id='label_2_58_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_2_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_59\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_59\"><legend class='gfield_label gform-field-label'  >Heart \/ Circulatory Problems(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_59'>\n\t\t\t<div class='gchoice gchoice_2_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Yes'  id='choice_2_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_2_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_57\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><strong>High Blood Pressure<\/strong><\/div><fieldset id=\"field_2_61\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><legend class='gfield_label gform-field-label'  >High Blood Pressure(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_61'>\n\t\t\t<div class='gchoice gchoice_2_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Yes'  id='choice_2_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_0' id='label_2_61_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='No'  id='choice_2_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_61_1' id='label_2_61_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_62\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><legend class='gfield_label gform-field-label'  >High Blood Pressure(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_62'>\n\t\t\t<div class='gchoice gchoice_2_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_2_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_2_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_60\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><strong>Stomach or Bowel Problems<\/strong><\/div><fieldset id=\"field_2_64\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><legend class='gfield_label gform-field-label'  >Stomach or Bowel Problems(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_64'>\n\t\t\t<div class='gchoice gchoice_2_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Yes'  id='choice_2_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_0' id='label_2_64_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='No'  id='choice_2_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_64_1' id='label_2_64_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_65\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><legend class='gfield_label gform-field-label'  >Stomach or Bowel Problems(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_65'>\n\t\t\t<div class='gchoice gchoice_2_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Yes'  id='choice_2_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_65_0' id='label_2_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='No'  id='choice_2_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_65_1' id='label_2_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_63\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><strong>Broken Bones<\/strong><\/div><fieldset id=\"field_2_67\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_67\"><legend class='gfield_label gform-field-label'  >Broken Bones(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_67'>\n\t\t\t<div class='gchoice gchoice_2_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_2_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_67_0' id='label_2_67_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='No'  id='choice_2_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_67_1' id='label_2_67_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_68\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_68\"><legend class='gfield_label gform-field-label'  >Broken Bones(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_68'>\n\t\t\t<div class='gchoice gchoice_2_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_2_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_68_0' id='label_2_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_2_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_68_1' id='label_2_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_66\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_66\"><strong>Skin Disease<\/strong><\/div><fieldset id=\"field_2_70\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_70\"><legend class='gfield_label gform-field-label'  >Skin Disease(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_70'>\n\t\t\t<div class='gchoice gchoice_2_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_2_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_70_0' id='label_2_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_2_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_70_1' id='label_2_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_71\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_71\"><legend class='gfield_label gform-field-label'  >Skin Disease(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_71'>\n\t\t\t<div class='gchoice gchoice_2_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_2_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_71_0' id='label_2_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_2_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_71_1' id='label_2_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_69\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_69\"><strong>Prostate Disease \/ Hormone Therapy<\/strong><\/div><fieldset id=\"field_2_73\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_73\"><legend class='gfield_label gform-field-label'  >Prostate Disease \/ Hormone Therapy(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_73'>\n\t\t\t<div class='gchoice gchoice_2_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Yes'  id='choice_2_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_73_0' id='label_2_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='No'  id='choice_2_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_73_1' id='label_2_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_74\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_74\"><legend class='gfield_label gform-field-label'  >Prostate Disease \/ Hormone Therapy(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_74'>\n\t\t\t<div class='gchoice gchoice_2_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_2_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_74_0' id='label_2_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_2_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_74_1' id='label_2_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_72\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\"><strong>Depression, Anxiety, etc.<\/strong><\/div><fieldset id=\"field_2_76\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_76\"><legend class='gfield_label gform-field-label'  >Depression, Anxiety, etc.(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_76'>\n\t\t\t<div class='gchoice gchoice_2_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_2_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_0' id='label_2_76_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_2_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_76_1' id='label_2_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_77\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_77\"><legend class='gfield_label gform-field-label'  >Depression, Anxiety, etc.(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_77'>\n\t\t\t<div class='gchoice gchoice_2_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_2_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_0' id='label_2_77_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_2_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_1' id='label_2_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_75\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_75\"><strong>Painful or Irregular Menstrual Cycles<\/strong><\/div><fieldset id=\"field_2_79\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_79\"><legend class='gfield_label gform-field-label'  >Painful or Irregular Menstrual Cycles(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_79'>\n\t\t\t<div class='gchoice gchoice_2_79_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='Yes'  id='choice_2_79_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_79_0' id='label_2_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_79_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_79' type='radio' value='No'  id='choice_2_79_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_79_1' id='label_2_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_80\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_80\"><legend class='gfield_label gform-field-label'  >Painful or Irregular Menstrual Cycles(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_80'>\n\t\t\t<div class='gchoice gchoice_2_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_2_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_2_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_81\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_81\"><strong>Tendonitis<\/strong><\/div><fieldset id=\"field_2_82\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_82\"><legend class='gfield_label gform-field-label'  >Tendonitis(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_82'>\n\t\t\t<div class='gchoice gchoice_2_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_2_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_0' id='label_2_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_2_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_1' id='label_2_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_83\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_83\"><legend class='gfield_label gform-field-label'  >Tendonitis(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_83'>\n\t\t\t<div class='gchoice gchoice_2_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_2_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_83_0' id='label_2_83_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_2_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_83_1' id='label_2_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_78\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\"><strong>Exercise on a Regular Basis<\/strong><\/div><fieldset id=\"field_2_85\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_85\"><legend class='gfield_label gform-field-label'  >Exercise on a Regular Basis(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_85'>\n\t\t\t<div class='gchoice gchoice_2_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Yes'  id='choice_2_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_0' id='label_2_85_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='No'  id='choice_2_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_1' id='label_2_85_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_86\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_86\"><legend class='gfield_label gform-field-label'  >Exercise on a Regular Basis(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_86'>\n\t\t\t<div class='gchoice gchoice_2_86_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='Yes'  id='choice_2_86_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_86_0' id='label_2_86_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_86_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_86' type='radio' value='No'  id='choice_2_86_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_86_1' id='label_2_86_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_84\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\"><strong>Motor Vehicle Accident or Other Injuries<\/strong><\/div><fieldset id=\"field_2_88\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_88\"><legend class='gfield_label gform-field-label'  >Motor Vehicle Accident or Other Injuries(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_88'>\n\t\t\t<div class='gchoice gchoice_2_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_2_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_88_0' id='label_2_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_2_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_88_1' id='label_2_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_89\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_89\"><legend class='gfield_label gform-field-label'  >Motor Vehicle Accident or Other Injuries(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_89'>\n\t\t\t<div class='gchoice gchoice_2_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Yes'  id='choice_2_89_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_89_0' id='label_2_89_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='No'  id='choice_2_89_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_89_1' id='label_2_89_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_87\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_87\"><strong>Alcohol \/ Nicotine Use<\/strong><\/div><fieldset id=\"field_2_91\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_91\"><legend class='gfield_label gform-field-label'  >Alcohol \/ Nicotine Use(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_91'>\n\t\t\t<div class='gchoice gchoice_2_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_2_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_0' id='label_2_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_2_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_91_1' id='label_2_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_92\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_92\"><legend class='gfield_label gform-field-label'  >Alcohol \/ Nicotine Use(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_92'>\n\t\t\t<div class='gchoice gchoice_2_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Yes'  id='choice_2_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_0' id='label_2_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='No'  id='choice_2_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_92_1' id='label_2_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_90\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_90\"><strong>Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough<\/strong><\/div><fieldset id=\"field_2_94\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_94\"><legend class='gfield_label gform-field-label'  >Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_94'>\n\t\t\t<div class='gchoice gchoice_2_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='Yes'  id='choice_2_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_94_0' id='label_2_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='No'  id='choice_2_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_94_1' id='label_2_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_95\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_95\"><legend class='gfield_label gform-field-label'  >Allergies \/ Upper Respiratory Infection \/ Flu \/ Cough(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_95'>\n\t\t\t<div class='gchoice gchoice_2_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Yes'  id='choice_2_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_0' id='label_2_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='No'  id='choice_2_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_93\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_93\"><strong>Surgeries<\/strong><\/div><fieldset id=\"field_2_97\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_97\"><legend class='gfield_label gform-field-label'  >Surgeries(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_97'>\n\t\t\t<div class='gchoice gchoice_2_97_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='Yes'  id='choice_2_97_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_0' id='label_2_97_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_97_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_97' type='radio' value='No'  id='choice_2_97_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_98\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_98\"><legend class='gfield_label gform-field-label'  >Surgeries(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_98'>\n\t\t\t<div class='gchoice gchoice_2_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_2_98_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_0' id='label_2_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_2_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_98_1' id='label_2_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_96\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_96\"><strong>Chiropractic Treatment Before<\/strong><\/div><fieldset id=\"field_2_100\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_100\"><legend class='gfield_label gform-field-label'  >Chiropractic Treatment Before(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_100'>\n\t\t\t<div class='gchoice gchoice_2_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_2_100_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_0' id='label_2_100_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_2_100_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_100_1' id='label_2_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_101\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_101\"><legend class='gfield_label gform-field-label'  >Chiropractic Treatment Before(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_101'>\n\t\t\t<div class='gchoice gchoice_2_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_2_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_0' id='label_2_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_2_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_101_1' id='label_2_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_99\"  class=\"gfield gfield--type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_99\"><strong>Unintended Weight Gain \/ Loss<\/strong><\/div><fieldset id=\"field_2_103\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_103\"><legend class='gfield_label gform-field-label'  >Unintended Weight Gain \/ Loss(You)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_103'>\n\t\t\t<div class='gchoice gchoice_2_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_2_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_0' id='label_2_103_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_2_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_103_1' id='label_2_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_104\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_104\"><legend class='gfield_label gform-field-label'  >Unintended Weight Gain \/ Loss(Family Member)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_104'>\n\t\t\t<div class='gchoice gchoice_2_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_2_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_0' id='label_2_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_2_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_104_1' id='label_2_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_102\"  class=\"gfield 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