{"id":220,"date":"2025-02-10T18:00:59","date_gmt":"2025-02-10T18:00:59","guid":{"rendered":"https:\/\/fideshealthinternational.com\/?page_id=220"},"modified":"2025-02-10T18:01:45","modified_gmt":"2025-02-10T18:01:45","slug":"saglik-kontrol-formu","status":"publish","type":"page","link":"https:\/\/fideshealthinternational.com\/en\/saglik-kontrol-formu\/","title":{"rendered":"Health Check Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"220\" class=\"elementor elementor-220\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b72436e e-flex e-con-boxed e-con e-parent\" data-id=\"b72436e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bfd58b5 elementor-widget elementor-widget-heading\" data-id=\"bfd58b5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Sa\u011fl\u0131k Kontrol Formu<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-5510756 e-flex e-con-boxed e-con e-parent\" data-id=\"5510756\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d0204b6 elementor-widget elementor-widget-shortcode\" data-id=\"d0204b6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_2_container\" data-token=\"0c05cfceb513165ccc3b34953e164017\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_healtcheckform\" data-token=\"0c05cfceb513165ccc3b34953e164017\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Healt Check Form<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"2\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_2\" id=\"frm_hide_fields_2\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"healtcheckform\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_2\" name=\"frm_submit_entry_2\" value=\"0980c0cf43\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/220\" \/><div id=\"frm_field_6_container\" class=\"frm_form_field frm_section_heading form-field frm_top_container\">\r\n<h3 class=\"frm_pos_ frm_primary_label[collapse_class]\">Please fill in the information below<\/h3>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_7_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first frm_three_col\">\r\n    <div  id=\"field_niq4f_label\" class=\"frm_primary_label\">Selection of Surgery \/ Procudures?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_niq4f_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-0\">\t\t\t<label  for=\"field_niq4f-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-0\" value=\"Gastric \/ Obesity Procudures\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   aria-required=\"true\"  \/> Gastric \/ Obesity Procudures<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-1\">\t\t\t<label  for=\"field_niq4f-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-1\" value=\"Aesthetic \/ Cosmetic\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   \/> Aesthetic \/ Cosmetic<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-2\">\t\t\t<label  for=\"field_niq4f-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-2\" value=\"Hair Transplant\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   \/> Hair Transplant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-3\">\t\t\t<label  for=\"field_niq4f-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-3\" value=\"Dentistry\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   \/> Dentistry<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-4\">\t\t\t<label  for=\"field_niq4f-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-4\" value=\"General Surgery\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   \/> General Surgery<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_7-6-5\">\t\t\t<label  for=\"field_niq4f-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[7][]\" id=\"field_niq4f-5\" value=\"Orthopedic Surgery\"  data-reqmsg=\"Selection of Surgery \/ Procudures? cannot be blank.\" data-invmsg=\"Selection of Surgery \/ Procudures? is invalid\"   \/> Orthopedic Surgery<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_8_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <div  id=\"field_xledr_label\" class=\"frm_primary_label\">Name Surname\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_xledr_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName Surname\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_8\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_8-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_xledr_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_xledr_first\" value=\"\" name=\"item_meta[8][first]\" autocomplete=\"given-name\" data-reqmsg=\"Name Surname cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name Surname is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_8_first_desc\">First<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_8-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_xledr_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_xledr_last\" value=\"\" name=\"item_meta[8][last]\" autocomplete=\"family-name\" data-reqmsg=\"Name Surname cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name Surname is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_8_last_desc\">Last<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_9_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_e4txe\" id=\"field_e4txe_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_e4txe\" name=\"item_meta[9]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_10_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_p9j4n\" id=\"field_p9j4n_label\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_p9j4n\" name=\"item_meta[10]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_11_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_3vlxd\" id=\"field_3vlxd_label\" class=\"frm_primary_label\">Section Buttons\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_3vlxd\" name=\"item_meta[11]\" value=\"\"  data-invmsg=\"Section Buttons is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_12_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_9kyhp_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <input type=\"text\" id=\"field_9kyhp\" name=\"item_meta[12]\" value=\", , , , , \"  data-frmval=\"{&quot;line1&quot;:&quot;&quot;,&quot;line2&quot;:&quot;&quot;,&quot;city&quot;:&quot;&quot;,&quot;state&quot;:&quot;&quot;,&quot;zip&quot;:&quot;&quot;,&quot;country&quot;:&quot;&quot;}\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_13_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm12 frm_first\">\r\n    <label for=\"field_ngwol\" id=\"field_ngwol_label\" class=\"frm_primary_label\">Occupation\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ngwol\" name=\"item_meta[13]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_14_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_teowb\" id=\"field_teowb_label\" class=\"frm_primary_label\">Emergency  Contact Person Name Surname\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_teowb\" name=\"item_meta[14]\" value=\"\"  data-reqmsg=\"Emergency  Contact Person Name Surname cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_e99jg\" id=\"field_e99jg_label\" class=\"frm_primary_label\">Emergency  Contact Person Phone Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_e99jg\" name=\"item_meta[15]\" value=\"\"  data-reqmsg=\"Emergency  Contact Person Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"frm_form_field frm_section_heading form-field frm_top_container\">\r\n<h3 class=\"frm_pos_ frm_primary_label[collapse_class]\">Medical History<\/h3>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_z8go4\" id=\"field_z8go4_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_z8go4\" name=\"item_meta[17]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_four_col\">\r\n    <div  id=\"field_svvgt_label\" class=\"frm_primary_label\">Sex\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_svvgt_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_18-16-0\">\t\t\t<label  for=\"field_svvgt-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[18][]\" id=\"field_svvgt-0\" value=\"Male\"  data-reqmsg=\"Sex cannot be blank.\" data-invmsg=\"Sex is invalid\"   aria-required=\"true\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_18-16-1\">\t\t\t<label  for=\"field_svvgt-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[18][]\" id=\"field_svvgt-1\" value=\"Female\"  data-reqmsg=\"Sex cannot be blank.\" data-invmsg=\"Sex is invalid\"   \/> Female<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_7afvu\" id=\"field_7afvu_label\" class=\"frm_primary_label\">Height\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7afvu\" name=\"item_meta[19]\" value=\"\"  data-reqmsg=\"Height cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_ldtmq\" id=\"field_ldtmq_label\" class=\"frm_primary_label\">Weight\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ldtmq\" name=\"item_meta[20]\" value=\"\"  data-reqmsg=\"Weight cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_lhm0s\" id=\"field_lhm0s_label\" class=\"frm_primary_label\">BMI Index\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lhm0s\" name=\"item_meta[21]\" value=\"\"  data-reqmsg=\"BMI Index cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_86sue_label\" class=\"frm_primary_label\">Do you smoke on a daily basis?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_86sue_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_22-16-0\">\t\t\t<label  for=\"field_86sue-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[22][]\" id=\"field_86sue-0\" value=\"Yes\"  data-reqmsg=\"Do you smoke on a daily basis? cannot be blank.\" data-invmsg=\"Do you smoke on a daily basis? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_22-16-1\">\t\t\t<label  for=\"field_86sue-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[22][]\" id=\"field_86sue-1\" value=\"No\"  data-reqmsg=\"Do you smoke on a daily basis? cannot be blank.\" data-invmsg=\"Do you smoke on a daily basis? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_1hjt9_label\" class=\"frm_primary_label\">Do you drink alcohol \/ day?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_1hjt9_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-16-0\">\t\t\t<label  for=\"field_1hjt9-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_1hjt9-0\" value=\"Yes\"  data-reqmsg=\"Do you drink alcohol \/ day? cannot be blank.\" data-invmsg=\"Do you drink alcohol \/ day? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_23-16-1\">\t\t\t<label  for=\"field_1hjt9-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[23][]\" id=\"field_1hjt9-1\" value=\"No\"  data-reqmsg=\"Do you drink alcohol \/ day? cannot be blank.\" data-invmsg=\"Do you drink alcohol \/ day? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_vxjju\" id=\"field_vxjju_label\" class=\"frm_primary_label\">Do you have any allergies to medications or food you have? If so, could you please list them below?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[24]\" id=\"field_vxjju\" rows=\"5\"  data-reqmsg=\"Do you have any allergies to medications or food you have? If so, could you please list them below? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Do you have any allergies to medications or food you have? If so, could you please list them below? is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_q2tj4\" id=\"field_q2tj4_label\" class=\"frm_primary_label\">Please list any medical conditions \/ chronic diseases you have ( Heart Disease, Tachycardia, Arrhythmia, Hypertension, Stroke, Kidney Disease, Cancer, Diabetes, Hepatitis, Seizures, Depression, Asthma, High or Low Blood Pressure, Epilepsy,  Dizziness or Fainting, Shortness of breath, High Cholesterol, Difficulty Sleeping\/Apnea, Anxiety, Headaches or Migraines etc. )\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[25]\" id=\"field_q2tj4\" rows=\"5\"  data-reqmsg=\"Please list any medical conditions \/ chronic diseases you have ( Heart Disease, Tachycardia, Arrhythmia, Hypertension, Stroke, Kidney Disease, Cancer, Diabetes, Hepatitis, Seizures, Depression, Asthma, High or Low Blood Pressure, Epilepsy,  Dizziness or Fainting, Shortness of breath, High Cholesterol, Difficulty Sleeping\/Apnea, Anxiety, Headaches or Migraines etc. ) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please list any medical conditions \/ chronic diseases you have ( Heart Disease, Tachycardia, Arrhythmia, Hypertension, Stroke, Kidney Disease, Cancer, Diabetes, Hepatitis, Seizures, Depression, Asthma, High or Low Blood Pressure, Epilepsy,  Dizziness or Fainting, Shortness of breath, High Cholesterol, Difficulty Sleeping\/Apnea, Anxiety, Headaches or Migraines etc. ) is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_surop\" id=\"field_surop_label\" class=\"frm_primary_label\">Have any of your first-degree relatives experienced the following conditions?(Heart Attack, High Cholesterol, High Blood Pressure, Congenital Heart Disease, Diabetes )\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[26]\" id=\"field_surop\" rows=\"5\"  data-reqmsg=\"Have any of your first-degree relatives experienced the following conditions?(Heart Attack, High Cholesterol, High Blood Pressure, Congenital Heart Disease, Diabetes ) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Have any of your first-degree relatives experienced the following conditions?(Heart Attack, High Cholesterol, High Blood Pressure, Congenital Heart Disease, Diabetes ) is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_27_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_wus6b\" id=\"field_wus6b_label\" class=\"frm_primary_label\">Please list any gastric surgeries you have had.\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_wus6b\" name=\"item_meta[27]\" value=\"\"  data-reqmsg=\"Please list any gastric surgeries you have had. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_83td6\" id=\"field_83td6_label\" class=\"frm_primary_label\">Please list any cosmetic \/ aesthetic surgeries you have had.\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_83td6\" name=\"item_meta[28]\" value=\"\"  data-reqmsg=\"Please list any cosmetic \/ aesthetic surgeries you have had. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ftoqu\" id=\"field_ftoqu_label\" class=\"frm_primary_label\">Please list any surgeries other than cosmetic \/ gastric surgeries you have undergone.\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ftoqu\" name=\"item_meta[29]\" value=\"\"  data-reqmsg=\"Please list any surgeries other than cosmetic \/ gastric surgeries you have undergone. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_vhnqc\" id=\"field_vhnqc_label\" class=\"frm_primary_label\">Please list all medications with dosages that you are currently taking.\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_vhnqc\" name=\"item_meta[30]\" value=\"\"  data-reqmsg=\"Please list all medications with dosages that you are currently taking. cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_31_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_7uyvw\" id=\"field_7uyvw_label\" class=\"frm_primary_label\">If you are female, how many pregnancies to term have you had?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7uyvw\" name=\"item_meta[31]\" value=\"\"  data-reqmsg=\"If you are female, how many pregnancies to term have you had? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_fucn7\" id=\"field_fucn7_label\" class=\"frm_primary_label\">Do you have any blood or blood clotting disorders?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fucn7\" name=\"item_meta[32]\" value=\"\"  data-reqmsg=\"Do you have any blood or blood clotting disorders? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_coh1u_label\" class=\"frm_primary_label\">Have you had herpes in the past ?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_coh1u_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_33-16-0\">\t\t\t<label  for=\"field_coh1u-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[33][]\" id=\"field_coh1u-0\" value=\"Yes\"  data-reqmsg=\"Have you had herpes in the past ? cannot be blank.\" data-invmsg=\"Have you had herpes in the past ? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_33-16-1\">\t\t\t<label  for=\"field_coh1u-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[33][]\" id=\"field_coh1u-1\" value=\"No\"  data-reqmsg=\"Have you had herpes in the past ? cannot be blank.\" data-invmsg=\"Have you had herpes in the past ? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_6ujvq_label\" class=\"frm_primary_label\">Are you HIV positive?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_6ujvq_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_34-16-0\">\t\t\t<label  for=\"field_6ujvq-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[34][]\" id=\"field_6ujvq-0\" value=\"Yes\"  data-reqmsg=\"Are you HIV positive? cannot be blank.\" data-invmsg=\"Are you HIV positive? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_34-16-1\">\t\t\t<label  for=\"field_6ujvq-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[34][]\" id=\"field_6ujvq-1\" value=\"No\"  data-reqmsg=\"Are you HIV positive? cannot be blank.\" data-invmsg=\"Are you HIV positive? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_gtt35_label\" class=\"frm_primary_label\">Are you Hepatitis B positive?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_gtt35_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_35-16-0\">\t\t\t<label  for=\"field_gtt35-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[35][]\" id=\"field_gtt35-0\" value=\"Yes\"  data-reqmsg=\"Are you Hepatitis B positive? cannot be blank.\" data-invmsg=\"Are you Hepatitis B positive? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_35-16-1\">\t\t\t<label  for=\"field_gtt35-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[35][]\" id=\"field_gtt35-1\" value=\"No\"  data-reqmsg=\"Are you Hepatitis B positive? cannot be blank.\" data-invmsg=\"Are you Hepatitis B positive? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_36_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_ulh6x_label\" class=\"frm_primary_label\">Are you Hepatitis C positive?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ulh6x_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-16-0\">\t\t\t<label  for=\"field_ulh6x-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_ulh6x-0\" value=\"Yes\"  data-reqmsg=\"Are you Hepatitis C positive? cannot be blank.\" data-invmsg=\"Are you Hepatitis C positive? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_36-16-1\">\t\t\t<label  for=\"field_ulh6x-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[36][]\" id=\"field_ulh6x-1\" value=\"No\"  data-reqmsg=\"Are you Hepatitis C positive? cannot be blank.\" data-invmsg=\"Are you Hepatitis C positive? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_bd9n8_label\" class=\"frm_primary_label\">Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_bd9n8_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-16-0\">\t\t\t<label  for=\"field_bd9n8-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_bd9n8-0\" value=\"Yes\"  data-reqmsg=\"Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? cannot be blank.\" data-invmsg=\"Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_37-16-1\">\t\t\t<label  for=\"field_bd9n8-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[37][]\" id=\"field_bd9n8-1\" value=\"No\"  data-reqmsg=\"Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? cannot be blank.\" data-invmsg=\"Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_gvj2h\" id=\"field_gvj2h_label\" class=\"frm_primary_label\">If yes, to any of the above, what is your current status (virus free, cured, taking meds)?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_gvj2h\" name=\"item_meta[38]\" value=\"\"  data-reqmsg=\"If yes, to any of the above, what is your current status (virus free, cured, taking meds)? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_gm6jw_label\" class=\"frm_primary_label\">Have you had any problems with anesthesia in the past?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_gm6jw_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-16-0\">\t\t\t<label  for=\"field_gm6jw-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_gm6jw-0\" value=\"Yes\"  data-reqmsg=\"Have you had any problems with anesthesia in the past? cannot be blank.\" data-invmsg=\"Have you had any problems with anesthesia in the past? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_39-16-1\">\t\t\t<label  for=\"field_gm6jw-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[39][]\" id=\"field_gm6jw-1\" value=\"No\"  data-reqmsg=\"Have you had any problems with anesthesia in the past? cannot be blank.\" data-invmsg=\"Have you had any problems with anesthesia in the past? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_fv5uf\" id=\"field_fv5uf_label\" class=\"frm_primary_label\">If yes what happened and with what anesthesia agent?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_fv5uf\" name=\"item_meta[40]\" value=\"\"  data-reqmsg=\"If yes what happened and with what anesthesia agent? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_mu4q2_label\" class=\"frm_primary_label\">Can you take morphine?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_mu4q2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_41-16-0\">\t\t\t<label  for=\"field_mu4q2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[41][]\" id=\"field_mu4q2-0\" value=\"Yes\"  data-reqmsg=\"Can you take morphine? cannot be blank.\" data-invmsg=\"Can you take morphine? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_41-16-1\">\t\t\t<label  for=\"field_mu4q2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[41][]\" id=\"field_mu4q2-1\" value=\"No\"  data-reqmsg=\"Can you take morphine? cannot be blank.\" data-invmsg=\"Can you take morphine? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_42_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_jo4e4_label\" class=\"frm_primary_label\">Can you take demerol?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_jo4e4_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_42-16-0\">\t\t\t<label  for=\"field_jo4e4-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[42][]\" id=\"field_jo4e4-0\" value=\"Yes\"  data-reqmsg=\"Can you take demerol? cannot be blank.\" data-invmsg=\"Can you take demerol? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_42-16-1\">\t\t\t<label  for=\"field_jo4e4-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[42][]\" id=\"field_jo4e4-1\" value=\"No\"  data-reqmsg=\"Can you take demerol? cannot be blank.\" data-invmsg=\"Can you take demerol? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_43_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_3uwmw_label\" class=\"frm_primary_label\">Can you take epinephrine?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_3uwmw_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_43-16-0\">\t\t\t<label  for=\"field_3uwmw-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[43][]\" id=\"field_3uwmw-0\" value=\"Yes\"  data-reqmsg=\"Can you take epinephrine? cannot be blank.\" data-invmsg=\"Can you take epinephrine? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_43-16-1\">\t\t\t<label  for=\"field_3uwmw-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[43][]\" id=\"field_3uwmw-1\" value=\"No\"  data-reqmsg=\"Can you take epinephrine? cannot be blank.\" data-invmsg=\"Can you take epinephrine? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_44_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_9agx8_label\" class=\"frm_primary_label\">Do you have dry eyes?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_9agx8_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_44-16-0\">\t\t\t<label  for=\"field_9agx8-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][]\" id=\"field_9agx8-0\" value=\"Yes\"  data-reqmsg=\"Do you have dry eyes? cannot be blank.\" data-invmsg=\"Do you have dry eyes? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_44-16-1\">\t\t\t<label  for=\"field_9agx8-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[44][]\" id=\"field_9agx8-1\" value=\"No\"  data-reqmsg=\"Do you have dry eyes? cannot be blank.\" data-invmsg=\"Do you have dry eyes? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_45_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_trr42_label\" class=\"frm_primary_label\">Do you have lens implants in your eyes?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_trr42_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-16-0\">\t\t\t<label  for=\"field_trr42-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_trr42-0\" value=\"Yes\"  data-reqmsg=\"Do you have lens implants in your eyes? cannot be blank.\" data-invmsg=\"Do you have lens implants in your eyes? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_45-16-1\">\t\t\t<label  for=\"field_trr42-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[45][]\" id=\"field_trr42-1\" value=\"No\"  data-reqmsg=\"Do you have lens implants in your eyes? cannot be blank.\" data-invmsg=\"Do you have lens implants in your eyes? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_46_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_440lc_label\" class=\"frm_primary_label\">Have you ever been told you had an adhesive allergy?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_440lc_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-16-0\">\t\t\t<label  for=\"field_440lc-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_440lc-0\" value=\"Yes\"  data-reqmsg=\"Have you ever been told you had an adhesive allergy? cannot be blank.\" data-invmsg=\"Have you ever been told you had an adhesive allergy? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_46-16-1\">\t\t\t<label  for=\"field_440lc-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[46][]\" id=\"field_440lc-1\" value=\"No\"  data-reqmsg=\"Have you ever been told you had an adhesive allergy? cannot be blank.\" data-invmsg=\"Have you ever been told you had an adhesive allergy? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_47_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_a2hh0_label\" class=\"frm_primary_label\">Are you allergic to medical tape?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_a2hh0_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-16-0\">\t\t\t<label  for=\"field_a2hh0-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_a2hh0-0\" value=\"Yes\"  data-reqmsg=\"Are you allergic to medical tape? cannot be blank.\" data-invmsg=\"Are you allergic to medical tape? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_47-16-1\">\t\t\t<label  for=\"field_a2hh0-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[47][]\" id=\"field_a2hh0-1\" value=\"No\"  data-reqmsg=\"Are you allergic to medical tape? cannot be blank.\" data-invmsg=\"Are you allergic to medical tape? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_j53at_label\" class=\"frm_primary_label\">Latexallergy?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_j53at_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-16-0\">\t\t\t<label  for=\"field_j53at-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_j53at-0\" value=\"Yes\"  data-reqmsg=\"Latexallergy? cannot be blank.\" data-invmsg=\"Latexallergy? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_48-16-1\">\t\t\t<label  for=\"field_j53at-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[48][]\" id=\"field_j53at-1\" value=\"No\"  data-reqmsg=\"Latexallergy? cannot be blank.\" data-invmsg=\"Latexallergy? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_49_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_xy2x2_label\" class=\"frm_primary_label\">Do you have sleep apnea?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_xy2x2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-16-0\">\t\t\t<label  for=\"field_xy2x2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_xy2x2-0\" value=\"Yes\"  data-reqmsg=\"Do you have sleep apnea? cannot be blank.\" data-invmsg=\"Do you have sleep apnea? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_49-16-1\">\t\t\t<label  for=\"field_xy2x2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[49][]\" id=\"field_xy2x2-1\" value=\"No\"  data-reqmsg=\"Do you have sleep apnea? cannot be blank.\" data-invmsg=\"Do you have sleep apnea? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_be5or_label\" class=\"frm_primary_label\">If yes, do you wear CPAP at night?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_be5or_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_50-16-0\">\t\t\t<label  for=\"field_be5or-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[50][]\" id=\"field_be5or-0\" value=\"Yes\"  data-reqmsg=\"If yes, do you wear CPAP at night? cannot be blank.\" data-invmsg=\"If yes, do you wear CPAP at night? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_50-16-1\">\t\t\t<label  for=\"field_be5or-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[50][]\" id=\"field_be5or-1\" value=\"No\"  data-reqmsg=\"If yes, do you wear CPAP at night? cannot be blank.\" data-invmsg=\"If yes, do you wear CPAP at night? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_xizhv_label\" class=\"frm_primary_label\">Have you ever had a blood clot in your calf?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_xizhv_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_51-16-0\">\t\t\t<label  for=\"field_xizhv-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[51][]\" id=\"field_xizhv-0\" value=\"Yes\"  data-reqmsg=\"Have you ever had a blood clot in your calf? cannot be blank.\" data-invmsg=\"Have you ever had a blood clot in your calf? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_51-16-1\">\t\t\t<label  for=\"field_xizhv-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[51][]\" id=\"field_xizhv-1\" value=\"No\"  data-reqmsg=\"Have you ever had a blood clot in your calf? cannot be blank.\" data-invmsg=\"Have you ever had a blood clot in your calf? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_ipe5i_label\" class=\"frm_primary_label\">Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ipe5i_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_52-16-0\">\t\t\t<label  for=\"field_ipe5i-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[52][]\" id=\"field_ipe5i-0\" value=\"Yes\"  data-reqmsg=\"Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)? cannot be blank.\" data-invmsg=\"Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_52-16-1\">\t\t\t<label  for=\"field_ipe5i-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[52][]\" id=\"field_ipe5i-1\" value=\"No\"  data-reqmsg=\"Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)? cannot be blank.\" data-invmsg=\"Have you ever had a blood clot(s) traveling to your lungs (pulmonary embolus)? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_swqgi_label\" class=\"frm_primary_label\">Anemia?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_swqgi_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-16-0\">\t\t\t<label  for=\"field_swqgi-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_swqgi-0\" value=\"Yes\"  data-reqmsg=\"Anemia? cannot be blank.\" data-invmsg=\"Anemia? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_53-16-1\">\t\t\t<label  for=\"field_swqgi-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[53][]\" id=\"field_swqgi-1\" value=\"No\"  data-reqmsg=\"Anemia? cannot be blank.\" data-invmsg=\"Anemia? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_tyuso_label\" class=\"frm_primary_label\">Rectal Bleeding?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_tyuso_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_54-16-0\">\t\t\t<label  for=\"field_tyuso-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[54][]\" id=\"field_tyuso-0\" value=\"Yes\"  data-reqmsg=\"Rectal Bleeding? cannot be blank.\" data-invmsg=\"Rectal Bleeding? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_54-16-1\">\t\t\t<label  for=\"field_tyuso-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[54][]\" id=\"field_tyuso-1\" value=\"No\"  data-reqmsg=\"Rectal Bleeding? cannot be blank.\" data-invmsg=\"Rectal Bleeding? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_9flij_label\" class=\"frm_primary_label\">Constipation or Diarrhea?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_9flij_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_55-16-0\">\t\t\t<label  for=\"field_9flij-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[55][]\" id=\"field_9flij-0\" value=\"Yes\"  data-reqmsg=\"Constipation or Diarrhea? cannot be blank.\" data-invmsg=\"Constipation or Diarrhea? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_55-16-1\">\t\t\t<label  for=\"field_9flij-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[55][]\" id=\"field_9flij-1\" value=\"No\"  data-reqmsg=\"Constipation or Diarrhea? cannot be blank.\" data-invmsg=\"Constipation or Diarrhea? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first vertical_radio\">\r\n    <div  id=\"field_9ewaj_label\" class=\"frm_primary_label\">Oral antidiabetic pills?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_9ewaj_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-16-0\">\t\t\t<label  for=\"field_9ewaj-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_9ewaj-0\" value=\"Yes\"  data-reqmsg=\"Oral antidiabetic pills? cannot be blank.\" data-invmsg=\"Oral antidiabetic pills? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_56-16-1\">\t\t\t<label  for=\"field_9ewaj-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[56][]\" id=\"field_9ewaj-1\" value=\"No\"  data-reqmsg=\"Oral antidiabetic pills? cannot be blank.\" data-invmsg=\"Oral antidiabetic pills? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_v4wkv_label\" class=\"frm_primary_label\">Insulin?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_v4wkv_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_57-16-0\">\t\t\t<label  for=\"field_v4wkv-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[57][]\" id=\"field_v4wkv-0\" value=\"Yes\"  data-reqmsg=\"Insulin? cannot be blank.\" data-invmsg=\"Insulin? is invalid\"   aria-required=\"true\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_57-16-1\">\t\t\t<label  for=\"field_v4wkv-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[57][]\" id=\"field_v4wkv-1\" value=\"No\"  data-reqmsg=\"Insulin? cannot be blank.\" data-invmsg=\"Insulin? is invalid\"   \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_cjw7z\" id=\"field_cjw7z_label\" class=\"frm_primary_label\">Any drug allergies \/ adverse drug reactions?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_cjw7z\" name=\"item_meta[58]\" value=\"\"  data-reqmsg=\"Any drug allergies \/ adverse drug reactions? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_aj28b\" id=\"field_aj28b_label\" class=\"frm_primary_label\">Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics?\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_aj28b\" name=\"item_meta[59]\" value=\"\"  data-reqmsg=\"Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics? cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_6ie84\" id=\"field_6ie84_label\" class=\"frm_primary_label\">Notes\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[60]\" id=\"field_6ie84\" rows=\"5\"  data-reqmsg=\"Notes cannot be blank.\" aria-required=\"true\" data-invmsg=\"Notes is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_p611e\" id=\"field_p611e_label\" class=\"frm_primary_label\">Section Buttons\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_p611e\" name=\"item_meta[61]\" value=\"\"  data-invmsg=\"Section Buttons is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field \">\n    <label for=\"field_s0ris\" id=\"field_s0ris_label\" class=\"frm_primary_label\">Submit\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n    <\/label>\n    <div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit\" type=\"submit\"  >Submit<\/button>\r\n\r\n<\/div>\n    \n    \n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_63_container\">\n\t\t\t<label for=\"field_ds0q3\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_ds0q3\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[63]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"O3sCe5IcaPH8wnSXkIhvmnKJvqiiMbmzzTCE6HUJQrE=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"21\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Health Check Form<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_kad_post_transparent":"default","_kad_post_title":"hide","_kad_post_layout":"fullwidth","_kad_post_sidebar_id":"","_kad_post_content_style":"unboxed","_kad_post_vertical_padding":"hide","_kad_post_feature":"hide","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","footnotes":""},"class_list":["post-220","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/pages\/220","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/comments?post=220"}],"version-history":[{"count":4,"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/pages\/220\/revisions"}],"predecessor-version":[{"id":224,"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/pages\/220\/revisions\/224"}],"wp:attachment":[{"href":"https:\/\/fideshealthinternational.com\/en\/wp-json\/wp\/v2\/media?parent=220"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}