{"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=\"b2f7de19aef006136a8bb6af8094edf3\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_healtcheckform\" data-token=\"b2f7de19aef006136a8bb6af8094edf3\">\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=\"115f464d11\" \/><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 vertical_radio\">\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    <fieldset aria-labelledby=\"field_9kyhp_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_12\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-line1_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-line1 \"\n\t\t\t\tdata-sub-field-name=\"line1\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tAddress\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"text\" id=\"field_9kyhp_line1\" value=\"\" name=\"item_meta[12][line1]\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"   \/>\n\t\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-line2_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-line2 \"\n\t\t\t\tdata-sub-field-name=\"line2\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tAddress\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"text\" id=\"field_9kyhp_line2\" value=\"\" name=\"item_meta[12][line2]\"  placeholder=\"\" data-placeholder=\"\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"   \/>\n\t\t\t\t\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-city_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-city frm_third frm_first\"\n\t\t\t\tdata-sub-field-name=\"city\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_city\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tCity\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"text\" id=\"field_9kyhp_city\" value=\"\" name=\"item_meta[12][city]\"  placeholder=\"\" data-placeholder=\"\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"   \/>\n\t\t\t\t\n\t\t\t\t<div class=\"frm_description\">City<\/div>\t\t\t<\/div>\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-state_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-state frm_third\"\n\t\t\t\tdata-sub-field-name=\"state\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_state\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tState\/Province\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"text\" id=\"field_9kyhp_state\" value=\"\" name=\"item_meta[12][state]\"  placeholder=\"\" data-placeholder=\"\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"   \/>\n\t\t\t\t\n\t\t\t\t<div class=\"frm_description\">State\/Province<\/div>\t\t\t<\/div>\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-zip_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-zip frm_third\"\n\t\t\t\tdata-sub-field-name=\"zip\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tZip\/Postal\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"text\" id=\"field_9kyhp_zip\" value=\"\" name=\"item_meta[12][zip]\"  placeholder=\"\" data-placeholder=\"\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"   \/>\n\t\t\t\t\n\t\t\t\t<div class=\"frm_description\">Zip\/Postal<\/div>\t\t\t<\/div>\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_12-country_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-country \"\n\t\t\t\tdata-sub-field-name=\"country\"\n\t\t\t>\n\t\t\t\t<label for=\"field_9kyhp_country\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tCountry\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<select name=\"item_meta[12][country]\" id=\"field_9kyhp_country\"  placeholder=\"\" data-placeholder=\"\" data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid-line1=\"false\" aria-invalid-line2=\"false\" aria-invalid-city=\"false\" aria-invalid-state=\"false\" aria-invalid-zip=\"false\" aria-invalid-country=\"false\"  >\n\t\t\t\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t\t\t\t \t\t\t\t\t\t<\/option>\n\t\t\t\t\t\t<option  value=\"Afghanistan\" data-code=\"AF\">Afghanistan<\/option><option  value=\"Aland Islands\" data-code=\"AX\">Aland Islands<\/option><option  value=\"Albania\" data-code=\"AL\">Albania<\/option><option  value=\"Algeria\" data-code=\"DZ\">Algeria<\/option><option  value=\"American Samoa\" data-code=\"AS\">American Samoa<\/option><option  value=\"Andorra\" data-code=\"AD\">Andorra<\/option><option  value=\"Angola\" data-code=\"AO\">Angola<\/option><option  value=\"Anguilla\" data-code=\"AI\">Anguilla<\/option><option  value=\"Antarctica\" data-code=\"AQ\">Antarctica<\/option><option  value=\"Antigua and Barbuda\" data-code=\"AG\">Antigua and Barbuda<\/option><option  value=\"Argentina\" data-code=\"AR\">Argentina<\/option><option  value=\"Armenia\" data-code=\"AM\">Armenia<\/option><option  value=\"Aruba\" data-code=\"AW\">Aruba<\/option><option  value=\"Australia\" data-code=\"AU\">Australia<\/option><option  value=\"Austria\" data-code=\"AT\">Austria<\/option><option  value=\"Azerbaijan\" data-code=\"AZ\">Azerbaijan<\/option><option  value=\"Bahamas\" data-code=\"BS\">Bahamas<\/option><option  value=\"Bahrain\" data-code=\"BH\">Bahrain<\/option><option  value=\"Bangladesh\" data-code=\"BD\">Bangladesh<\/option><option  value=\"Barbados\" data-code=\"BB\">Barbados<\/option><option  value=\"Belarus\" data-code=\"BY\">Belarus<\/option><option  value=\"Belgium\" data-code=\"BE\">Belgium<\/option><option  value=\"Belize\" data-code=\"BZ\">Belize<\/option><option  value=\"Benin\" data-code=\"BJ\">Benin<\/option><option  value=\"Bermuda\" data-code=\"BM\">Bermuda<\/option><option  value=\"Bhutan\" data-code=\"BT\">Bhutan<\/option><option  value=\"Bolivia\" data-code=\"BO\">Bolivia<\/option><option  value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option  value=\"Bosnia and Herzegovina\" data-code=\"BA\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\" data-code=\"BW\">Botswana<\/option><option  value=\"Bouvet Island\" data-code=\"BV\">Bouvet Island<\/option><option  value=\"Brazil\" data-code=\"BR\">Brazil<\/option><option  value=\"British Indian Ocean Territory\" data-code=\"IO\">British Indian Ocean Territory<\/option><option  value=\"Brunei\" data-code=\"BN\">Brunei<\/option><option  value=\"Bulgaria\" data-code=\"BG\">Bulgaria<\/option><option  value=\"Burkina Faso\" data-code=\"BF\">Burkina Faso<\/option><option  value=\"Burundi\" data-code=\"BI\">Burundi<\/option><option  value=\"C&ocirc;te d&#039;Ivoire\">C&ocirc;te d&#039;Ivoire<\/option><option  value=\"Cambodia\" data-code=\"KH\">Cambodia<\/option><option  value=\"Cameroon\" data-code=\"CM\">Cameroon<\/option><option  value=\"Canada\" data-code=\"CA\">Canada<\/option><option  value=\"Cape Verde\" data-code=\"CV\">Cape Verde<\/option><option  value=\"Cayman Islands\" data-code=\"KY\">Cayman Islands<\/option><option  value=\"Central African Republic\" data-code=\"CF\">Central African Republic<\/option><option  value=\"Chad\" data-code=\"TD\">Chad<\/option><option  value=\"Chile\" data-code=\"CL\">Chile<\/option><option  value=\"China\" data-code=\"CN\">China<\/option><option  value=\"Christmas Island\" data-code=\"CX\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\" data-code=\"CO\">Colombia<\/option><option  value=\"Comoros\" data-code=\"KM\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\" data-code=\"CK\">Cook Islands<\/option><option  value=\"Costa Rica\" data-code=\"CR\">Costa Rica<\/option><option  value=\"Croatia\" data-code=\"HR\">Croatia<\/option><option  value=\"Cuba\" data-code=\"CU\">Cuba<\/option><option  value=\"Curacao\" data-code=\"CW\">Curacao<\/option><option  value=\"Cyprus\" data-code=\"CY\">Cyprus<\/option><option  value=\"Czech Republic\" data-code=\"CZ\">Czech Republic<\/option><option  value=\"Denmark\" data-code=\"DK\">Denmark<\/option><option  value=\"Djibouti\" data-code=\"DJ\">Djibouti<\/option><option  value=\"Dominica\" data-code=\"DM\">Dominica<\/option><option  value=\"Dominican Republic\" data-code=\"DO\">Dominican Republic<\/option><option  value=\"East Timor\" data-code=\"TL\">East Timor<\/option><option  value=\"Ecuador\" data-code=\"EC\">Ecuador<\/option><option  value=\"Egypt\" data-code=\"EG\">Egypt<\/option><option  value=\"El Salvador\" data-code=\"SV\">El Salvador<\/option><option  value=\"Equatorial Guinea\" data-code=\"GQ\">Equatorial Guinea<\/option><option  value=\"Eritrea\" data-code=\"ER\">Eritrea<\/option><option  value=\"Estonia\" data-code=\"EE\">Estonia<\/option><option  value=\"Ethiopia\" data-code=\"ET\">Ethiopia<\/option><option  value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option  value=\"Faroe Islands\" data-code=\"FO\">Faroe Islands<\/option><option  value=\"Fiji\" data-code=\"FJ\">Fiji<\/option><option  value=\"Finland\" data-code=\"FI\">Finland<\/option><option  value=\"France\" data-code=\"FR\">France<\/option><option  value=\"French Guiana\" data-code=\"GF\">French Guiana<\/option><option  value=\"French Polynesia\" data-code=\"PF\">French Polynesia<\/option><option  value=\"French Southern Territories\" data-code=\"TF\">French Southern Territories<\/option><option  value=\"Gabon\" data-code=\"GA\">Gabon<\/option><option  value=\"Gambia\" data-code=\"GM\">Gambia<\/option><option  value=\"Georgia\" data-code=\"GE\">Georgia<\/option><option  value=\"Germany\" data-code=\"DE\">Germany<\/option><option  value=\"Ghana\" data-code=\"GH\">Ghana<\/option><option  value=\"Gibraltar\" data-code=\"GI\">Gibraltar<\/option><option  value=\"Greece\" data-code=\"GR\">Greece<\/option><option  value=\"Greenland\" data-code=\"GL\">Greenland<\/option><option  value=\"Grenada\" data-code=\"GD\">Grenada<\/option><option  value=\"Guadeloupe\" data-code=\"GP\">Guadeloupe<\/option><option  value=\"Guam\" data-code=\"GU\">Guam<\/option><option  value=\"Guatemala\" data-code=\"GT\">Guatemala<\/option><option  value=\"Guernsey\" data-code=\"GG\">Guernsey<\/option><option  value=\"Guinea\" data-code=\"GN\">Guinea<\/option><option  value=\"Guinea-Bissau\" data-code=\"GW\">Guinea-Bissau<\/option><option  value=\"Guyana\" data-code=\"GY\">Guyana<\/option><option  value=\"Haiti\" data-code=\"HT\">Haiti<\/option><option  value=\"Heard Island and McDonald Islands\" data-code=\"HM\">Heard Island and McDonald Islands<\/option><option  value=\"Holy See\">Holy See<\/option><option  value=\"Honduras\" data-code=\"HN\">Honduras<\/option><option  value=\"Hong Kong\" data-code=\"HK\">Hong Kong<\/option><option  value=\"Hungary\" data-code=\"HU\">Hungary<\/option><option  value=\"Iceland\" data-code=\"IS\">Iceland<\/option><option  value=\"India\" data-code=\"IN\">India<\/option><option  value=\"Indonesia\" data-code=\"ID\">Indonesia<\/option><option  value=\"Iran\" data-code=\"IR\">Iran<\/option><option  value=\"Iraq\" data-code=\"IQ\">Iraq<\/option><option  value=\"Ireland\" data-code=\"IE\">Ireland<\/option><option  value=\"Isle of Man\" data-code=\"IM\">Isle of Man<\/option><option  value=\"Israel\" data-code=\"IL\">Israel<\/option><option  value=\"Italy\" data-code=\"IT\">Italy<\/option><option  value=\"Jamaica\" data-code=\"JM\">Jamaica<\/option><option  value=\"Japan\" data-code=\"JP\">Japan<\/option><option  value=\"Jersey\" data-code=\"JE\">Jersey<\/option><option  value=\"Jordan\" data-code=\"JO\">Jordan<\/option><option  value=\"Kazakhstan\" data-code=\"KZ\">Kazakhstan<\/option><option  value=\"Kenya\" data-code=\"KE\">Kenya<\/option><option  value=\"Kiribati\" data-code=\"KI\">Kiribati<\/option><option  value=\"Kosovo\" data-code=\"XK\">Kosovo<\/option><option  value=\"Kuwait\" data-code=\"KW\">Kuwait<\/option><option  value=\"Kyrgyzstan\" data-code=\"KG\">Kyrgyzstan<\/option><option  value=\"Laos\" data-code=\"LA\">Laos<\/option><option  value=\"Latvia\" data-code=\"LV\">Latvia<\/option><option  value=\"Lebanon\" data-code=\"LB\">Lebanon<\/option><option  value=\"Lesotho\" data-code=\"LS\">Lesotho<\/option><option  value=\"Liberia\" data-code=\"LR\">Liberia<\/option><option  value=\"Libya\" data-code=\"LY\">Libya<\/option><option  value=\"Liechtenstein\" data-code=\"LI\">Liechtenstein<\/option><option  value=\"Lithuania\" data-code=\"LT\">Lithuania<\/option><option  value=\"Luxembourg\" data-code=\"LU\">Luxembourg<\/option><option  value=\"Macao\" data-code=\"MO\">Macao<\/option><option  value=\"Macedonia\" data-code=\"MK\">Macedonia<\/option><option  value=\"Madagascar\" data-code=\"MG\">Madagascar<\/option><option  value=\"Malawi\" data-code=\"MW\">Malawi<\/option><option  value=\"Malaysia\" data-code=\"MY\">Malaysia<\/option><option  value=\"Maldives\" data-code=\"MV\">Maldives<\/option><option  value=\"Mali\" data-code=\"ML\">Mali<\/option><option  value=\"Malta\" data-code=\"MT\">Malta<\/option><option  value=\"Marshall Islands\" data-code=\"MH\">Marshall Islands<\/option><option  value=\"Martinique\" data-code=\"MQ\">Martinique<\/option><option  value=\"Mauritania\" data-code=\"MR\">Mauritania<\/option><option  value=\"Mauritius\" data-code=\"MU\">Mauritius<\/option><option  value=\"Mayotte\" data-code=\"YT\">Mayotte<\/option><option  value=\"Mexico\" data-code=\"MX\">Mexico<\/option><option  value=\"Micronesia\" data-code=\"FM\">Micronesia<\/option><option  value=\"Moldova\" data-code=\"MD\">Moldova<\/option><option  value=\"Monaco\" data-code=\"MC\">Monaco<\/option><option  value=\"Mongolia\" data-code=\"MN\">Mongolia<\/option><option  value=\"Montenegro\" data-code=\"ME\">Montenegro<\/option><option  value=\"Montserrat\" data-code=\"MS\">Montserrat<\/option><option  value=\"Morocco\" data-code=\"MA\">Morocco<\/option><option  value=\"Mozambique\" data-code=\"MZ\">Mozambique<\/option><option  value=\"Myanmar\" data-code=\"MM\">Myanmar<\/option><option  value=\"Namibia\" data-code=\"NA\">Namibia<\/option><option  value=\"Nauru\" data-code=\"NR\">Nauru<\/option><option  value=\"Nepal\" data-code=\"NP\">Nepal<\/option><option  value=\"Netherlands\" data-code=\"NL\">Netherlands<\/option><option  value=\"New Caledonia\" data-code=\"NC\">New Caledonia<\/option><option  value=\"New Zealand\" data-code=\"NZ\">New Zealand<\/option><option  value=\"Nicaragua\" data-code=\"NI\">Nicaragua<\/option><option  value=\"Niger\" data-code=\"NE\">Niger<\/option><option  value=\"Nigeria\" data-code=\"NG\">Nigeria<\/option><option  value=\"Niue\" data-code=\"NU\">Niue<\/option><option  value=\"Norfolk Island\" data-code=\"NF\">Norfolk Island<\/option><option  value=\"North Korea\" data-code=\"KP\">North Korea<\/option><option  value=\"Northern Mariana Islands\" data-code=\"MP\">Northern Mariana Islands<\/option><option  value=\"Norway\" data-code=\"NO\">Norway<\/option><option  value=\"Oman\" data-code=\"OM\">Oman<\/option><option  value=\"Pakistan\" data-code=\"PK\">Pakistan<\/option><option  value=\"Palau\" data-code=\"PW\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\" data-code=\"PA\">Panama<\/option><option  value=\"Papua New Guinea\" data-code=\"PG\">Papua New Guinea<\/option><option  value=\"Paraguay\" data-code=\"PY\">Paraguay<\/option><option  value=\"Peru\" data-code=\"PE\">Peru<\/option><option  value=\"Philippines\" data-code=\"PH\">Philippines<\/option><option  value=\"Pitcairn\" data-code=\"PN\">Pitcairn<\/option><option  value=\"Poland\" data-code=\"PL\">Poland<\/option><option  value=\"Portugal\" data-code=\"PT\">Portugal<\/option><option  value=\"Puerto Rico\" data-code=\"PR\">Puerto Rico<\/option><option  value=\"Qatar\" data-code=\"QA\">Qatar<\/option><option  value=\"Reunion\" data-code=\"RE\">Reunion<\/option><option  value=\"Romania\" data-code=\"RO\">Romania<\/option><option  value=\"Russia\" data-code=\"RU\">Russia<\/option><option  value=\"Rwanda\" data-code=\"RW\">Rwanda<\/option><option  value=\"Saint Barthelemy\" data-code=\"BL\">Saint Barthelemy<\/option><option  value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option  value=\"Saint Kitts and Nevis\" data-code=\"KN\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\" data-code=\"LC\">Saint Lucia<\/option><option  value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option  value=\"Saint Pierre and Miquelon\" data-code=\"PM\">Saint Pierre and Miquelon<\/option><option  value=\"Saint Vincent and the Grenadines\" data-code=\"VC\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\" data-code=\"WS\">Samoa<\/option><option  value=\"San Marino\" data-code=\"SM\">San Marino<\/option><option  value=\"Sao Tome and Principe\" data-code=\"ST\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\" data-code=\"SA\">Saudi Arabia<\/option><option  value=\"Senegal\" data-code=\"SN\">Senegal<\/option><option  value=\"Serbia\" data-code=\"RS\">Serbia<\/option><option  value=\"Seychelles\" data-code=\"SC\">Seychelles<\/option><option  value=\"Sierra Leone\" data-code=\"SL\">Sierra Leone<\/option><option  value=\"Singapore\" data-code=\"SG\">Singapore<\/option><option  value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option  value=\"Slovakia\" data-code=\"SK\">Slovakia<\/option><option  value=\"Slovenia\" data-code=\"SI\">Slovenia<\/option><option  value=\"Solomon Islands\" data-code=\"SB\">Solomon Islands<\/option><option  value=\"Somalia\" data-code=\"SO\">Somalia<\/option><option  value=\"South Africa\" data-code=\"ZA\">South Africa<\/option><option  value=\"South Georgia and the South Sandwich Islands\" data-code=\"GS\">South Georgia and the South Sandwich Islands<\/option><option  value=\"South Korea\" data-code=\"KR\">South Korea<\/option><option  value=\"South Sudan\" data-code=\"SS\">South Sudan<\/option><option  value=\"Spain\" data-code=\"ES\">Spain<\/option><option  value=\"Sri Lanka\" data-code=\"LK\">Sri Lanka<\/option><option  value=\"Sudan\" data-code=\"SD\">Sudan<\/option><option  value=\"Suriname\" data-code=\"SR\">Suriname<\/option><option  value=\"Svalbard and Jan Mayen\" data-code=\"SJ\">Svalbard and Jan Mayen<\/option><option  value=\"Swaziland\" data-code=\"SZ\">Swaziland<\/option><option  value=\"Sweden\" data-code=\"SE\">Sweden<\/option><option  value=\"Switzerland\" data-code=\"CH\">Switzerland<\/option><option  value=\"Syria\" data-code=\"SY\">Syria<\/option><option  value=\"Taiwan\" data-code=\"TW\">Taiwan<\/option><option  value=\"Tajikistan\" data-code=\"TJ\">Tajikistan<\/option><option  value=\"Tanzania\" data-code=\"TZ\">Tanzania<\/option><option  value=\"Thailand\" data-code=\"TH\">Thailand<\/option><option  value=\"Timor-Leste\">Timor-Leste<\/option><option  value=\"Togo\" data-code=\"TG\">Togo<\/option><option  value=\"Tokelau\" data-code=\"TK\">Tokelau<\/option><option  value=\"Tonga\" data-code=\"TO\">Tonga<\/option><option  value=\"Trinidad and Tobago\" data-code=\"TT\">Trinidad and Tobago<\/option><option  value=\"Tunisia\" data-code=\"TN\">Tunisia<\/option><option  value=\"Turkey\" data-code=\"TR\">Turkey<\/option><option  value=\"Turkmenistan\" data-code=\"TM\">Turkmenistan<\/option><option  value=\"Turks and Caicos Islands\" data-code=\"TC\">Turks and Caicos Islands<\/option><option  value=\"Tuvalu\" data-code=\"TV\">Tuvalu<\/option><option  value=\"Uganda\" data-code=\"UG\">Uganda<\/option><option  value=\"Ukraine\" data-code=\"UA\">Ukraine<\/option><option  value=\"United Arab Emirates\" data-code=\"AE\">United Arab Emirates<\/option><option  value=\"United Kingdom\" data-code=\"GB\">United Kingdom<\/option><option  value=\"United States\" data-code=\"US\">United States<\/option><option  value=\"United States Minor Outlying Islands\" data-code=\"UM\">United States Minor Outlying Islands<\/option><option  value=\"Uruguay\" data-code=\"UY\">Uruguay<\/option><option  value=\"Uzbekistan\" data-code=\"UZ\">Uzbekistan<\/option><option  value=\"Vanuatu\" data-code=\"VU\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\" data-code=\"VE\">Venezuela<\/option><option  value=\"Vietnam\" data-code=\"VN\">Vietnam<\/option><option  value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option  value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option  value=\"Wallis and Futuna\" data-code=\"WF\">Wallis and Futuna<\/option><option  value=\"Western Sahara\" data-code=\"EH\">Western Sahara<\/option><option  value=\"Yemen\" data-code=\"YE\">Yemen<\/option><option  value=\"Zambia\" data-code=\"ZM\">Zambia<\/option><option  value=\"Zimbabwe\" data-code=\"ZW\">Zimbabwe<\/option>\t\t\t\t\t<\/select>\n\t\t\t\t\n\t\t\t\t<div class=\"frm_description\">Country<\/div>\t\t\t<\/div>\n\t\t\t<\/div>\n<\/fieldset>\n\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 vertical_radio\">\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_kdbow\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_kdbow\" 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=\"94\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/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}]}}