{"id":1232,"date":"2025-06-03T10:28:05","date_gmt":"2025-06-03T10:28:05","guid":{"rendered":"https:\/\/beta10.technodreamcenter.com\/atmybesthealth.com\/?page_id=1232"},"modified":"2025-06-10T01:56:46","modified_gmt":"2025-06-10T01:56:46","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/beta10.technodreamcenter.com\/atmybesthealth.com\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1232\" class=\"elementor elementor-1232\">\n\t\t\t\t<div class=\"elementor-element elementor-element-23cfd11 e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"23cfd11\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-3474ba9 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-child\" data-id=\"3474ba9\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-beb3bb5 elementor-widget__width-inherit elementor-widget elementor-widget-heading\" data-id=\"beb3bb5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">\nNew Patient Questionnaire<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5e6abef elementor-widget elementor-widget-text-editor\" data-id=\"5e6abef\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1228 forminator-design--basic  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1228\" data-uid=\"69e15d169ea87\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1228\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1228 forminator-design--basic  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1228\"\n\t\t\t\t\n\t\t\t\tdata-design=\"basic\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e15d169ea87\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Contact Information<\/h2><h3 class=\"forminator-subtitle\">Please fill out your contact information below.<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69e15d169ea87\" id=\"forminator-field-name-2_69e15d169ea87-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"Last Name\" id=\"forminator-field-name-2_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69e15d169ea87\" id=\"forminator-field-name-1_69e15d169ea87-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"First Name\" id=\"forminator-field-name-1_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e15d169ea87\" id=\"forminator-field-address-1-street_address_69e15d169ea87-label\" class=\"forminator-label\">Address 1<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69e15d169ea87\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e15d169ea87\" id=\"forminator-field-address-1-address_line_69e15d169ea87-label\" class=\"forminator-label\">Address 2<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e15d169ea87\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e15d169ea87\" id=\"forminator-field-address-1-city_69e15d169ea87-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69e15d169ea87\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69e15d169ea87\" id=\"forminator-field-address-1-state_69e15d169ea87-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_69e15d169ea87\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e15d169ea87\" id=\"forminator-field-address-1-zip_69e15d169ea87-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_69e15d169ea87\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-1228__field--address-1-country_69e15d169ea87\" id=\"forminator-field-1228__field--address-1-country_69e15d169ea87-label\" class=\"forminator-label\">Country<\/label><select name=\"address-1-country\" id=\"forminator-field-1228__field--address-1-country_69e15d169ea87\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People&#8217;s Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d&#8217;Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People&#8217;s Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People&#8217;s Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre &#038; Miquelon\" data-country-code=\"PM\" >Saint Pierre &#038; Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e15d169ea87\" id=\"forminator-field-phone-1_69e15d169ea87-label\" class=\"forminator-label\">Home Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e15d169ea87\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e15d169ea87\" id=\"forminator-field-phone-2_69e15d169ea87-label\" class=\"forminator-label\">Work Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69e15d169ea87\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-row-inside forminator-row-with-confirmation-email\"><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e15d169ea87\" id=\"forminator-field-email-1_69e15d169ea87-label\" class=\"forminator-label\">Email<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69e15d169ea87\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><div class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-confirm_email-1_69e15d169ea87\" id=\"forminator-field-confirm_email-1_69e15d169ea87-label\" class=\"forminator-label\">Confirm Email Address<\/label><input type=\"email\" name=\"confirm_email-1\" value=\"\" placeholder=\"Re-type Email Address\" id=\"forminator-field-confirm_email-1_69e15d169ea87\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69e15d169ea87-label\"><span id=\"forminator-radiogroup-radio-1-69e15d169ea87-label\" class=\"forminator-label\">Gender<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e15d169ea87\" class=\"forminator-radio\" title=\"Male\"><input type=\"radio\" name=\"radio-1\" value=\"Male\" id=\"forminator-field-radio-1-1-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Male<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e15d169ea87\" class=\"forminator-radio\" title=\"Female\"><input type=\"radio\" name=\"radio-1\" value=\"Female\" id=\"forminator-field-radio-1-2-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Female<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69e15d169ea87\" id=\"forminator-field-date-1-picker_69e15d169ea87-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69e15d169ea87\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69e15d169ea87\" id=\"forminator-field-textarea-1_69e15d169ea87-label\" class=\"forminator-label\">Current Complaint<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69e15d169ea87\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69e15d169ea87\" id=\"forminator-field-textarea-2_69e15d169ea87-label\" class=\"forminator-label\">Medications<\/label><span id=\"forminator-field-textarea-2_69e15d169ea87-description\" class=\"forminator-description\">Please list all medications you are taking along with the how many times a day and the dosage<\/span><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_69e15d169ea87\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" aria-describedby=\"forminator-field-textarea-2_69e15d169ea87-description\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Past Medical History<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69e15d169ea87-label\"><label id=\"forminator-field-checkbox-1-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-1-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cancer\" id=\"forminator-field-checkbox-1-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-1-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-1-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-1-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other heart trouble\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other-heart-trouble\" id=\"forminator-field-checkbox-1-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other heart trouble<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-7-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Asthma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Asthma\" id=\"forminator-field-checkbox-1-7-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-7-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-8-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Pneumonia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Pneumonia\" id=\"forminator-field-checkbox-1-8-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-8-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pneumonia<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-9-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Stroke\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Stroke\" id=\"forminator-field-checkbox-1-9-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-9-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Stroke<\/span><\/label><label id=\"forminator-field-checkbox-1-10-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-10-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Epilepsy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Epilepsy\" id=\"forminator-field-checkbox-1-10-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-10-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Epilepsy<\/span><\/label><label id=\"forminator-field-checkbox-1-11-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-11-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Anemia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anemia\" id=\"forminator-field-checkbox-1-11-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-11-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anemia<\/span><\/label><label id=\"forminator-field-checkbox-1-12-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-12-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Thyroid problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Thyroid-problems\" id=\"forminator-field-checkbox-1-12-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-12-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thyroid problems<\/span><\/label><label id=\"forminator-field-checkbox-1-13-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-13-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Chicken Pox\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Chicken-Pox\" id=\"forminator-field-checkbox-1-13-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-13-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Chicken Pox<\/span><\/label><label id=\"forminator-field-checkbox-1-14-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-14-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Valley Fever\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Valley-Fever\" id=\"forminator-field-checkbox-1-14-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-14-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Valley Fever<\/span><\/label><label id=\"forminator-field-checkbox-1-15-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-15-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Tuberculosis \/(+) skin test\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Tuberculosis--(+)-skin-test\" id=\"forminator-field-checkbox-1-15-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-15-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tuberculosis \/(+) skin test<\/span><\/label><label id=\"forminator-field-checkbox-1-16-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-16-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other stomach\/bowel disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Other-stomach-bowel-disease\" id=\"forminator-field-checkbox-1-16-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-16-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other stomach\/bowel disease<\/span><\/label><label id=\"forminator-field-checkbox-1-17-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-17-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Depression\/Anxiety\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Depression-Anxiety\" id=\"forminator-field-checkbox-1-17-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-17-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Depression\/Anxiety<\/span><\/label><label id=\"forminator-field-checkbox-1-18-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-18-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Glaucoma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Glaucoma\" id=\"forminator-field-checkbox-1-18-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-18-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Glaucoma<\/span><\/label><label id=\"forminator-field-checkbox-1-19-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-19-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Sexually Transmitted Disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Sexually-Transmitted-Disease\" id=\"forminator-field-checkbox-1-19-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-19-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Sexually Transmitted Disease<\/span><\/label><label id=\"forminator-field-checkbox-1-20-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-20-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Fractures\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Fractures\" id=\"forminator-field-checkbox-1-20-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-20-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fractures<\/span><\/label><label id=\"forminator-field-checkbox-1-21-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-21-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Headaches\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Headaches\" id=\"forminator-field-checkbox-1-21-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-21-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Headaches<\/span><\/label><label id=\"forminator-field-checkbox-1-22-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-22-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Neck problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Neck-problems\" id=\"forminator-field-checkbox-1-22-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-22-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Neck problems<\/span><\/label><label id=\"forminator-field-checkbox-1-23-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-23-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Back problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Back-problems\" id=\"forminator-field-checkbox-1-23-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-23-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Back problems<\/span><\/label><label id=\"forminator-field-checkbox-1-24-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-24-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Rheumatoid Arthritis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Rheumatoid-Arthritis\" id=\"forminator-field-checkbox-1-24-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-24-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rheumatoid Arthritis<\/span><\/label><label id=\"forminator-field-checkbox-1-25-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-25-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Osteoarthritis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Osteoarthritis\" id=\"forminator-field-checkbox-1-25-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-25-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Osteoarthritis<\/span><\/label><label id=\"forminator-field-checkbox-1-26-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-26-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Osteoporosis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Osteoporosis\" id=\"forminator-field-checkbox-1-26-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-26-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Osteoporosis<\/span><\/label><label id=\"forminator-field-checkbox-1-27-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-27-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Esphogeal reflux (GERD)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Esphogeal-reflux-(GERD)\" id=\"forminator-field-checkbox-1-27-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-27-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Esphogeal reflux (GERD)<\/span><\/label><label id=\"forminator-field-checkbox-1-28-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-28-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Kidney\/bladder disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Kidney-bladder-disease\" id=\"forminator-field-checkbox-1-28-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-28-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kidney\/bladder disease<\/span><\/label><label id=\"forminator-field-checkbox-1-29-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-29-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Hepatitis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Hepatitis\" id=\"forminator-field-checkbox-1-29-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-29-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hepatitis<\/span><\/label><label id=\"forminator-field-checkbox-1-30-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-30-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Peptic ulcer\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Peptic-ulcer\" id=\"forminator-field-checkbox-1-30-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-30-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Peptic ulcer<\/span><\/label><label id=\"forminator-field-checkbox-1-31-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-31-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Appendicitis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Appendicitis\" id=\"forminator-field-checkbox-1-31-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-31-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Appendicitis<\/span><\/label><label id=\"forminator-field-checkbox-1-32-69e15d169ea87-label\" for=\"forminator-field-checkbox-1-32-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Significant Accident\/Injury\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Significant-Accident-Injury\" id=\"forminator-field-checkbox-1-32-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-1-32-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Significant Accident\/Injury<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-69e15d169ea87-label\" class=\"forminator-label\">Immunizations<\/span><label id=\"forminator-field-checkbox-2-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Polio Vaccine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Polio-Vaccine\" id=\"forminator-field-checkbox-2-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Polio Vaccine<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"MMR Vaccine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"MMR-Vaccine\" id=\"forminator-field-checkbox-2-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">MMR Vaccine<\/span><\/label><label id=\"forminator-field-checkbox-2-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"DPT Vaccine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"DPT-Vaccine\" id=\"forminator-field-checkbox-2-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">DPT Vaccine<\/span><\/label><label id=\"forminator-field-checkbox-2-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Flu Shot (last 12 months)\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Flu-Shot-(last-12-months)\" id=\"forminator-field-checkbox-2-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Flu Shot (last 12 months)<\/span><\/label><label id=\"forminator-field-checkbox-2-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Pneumovax\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Pneumovax\" id=\"forminator-field-checkbox-2-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pneumovax<\/span><\/label><label id=\"forminator-field-checkbox-2-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Tetanus Shot\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Tetanus-Shot\" id=\"forminator-field-checkbox-2-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tetanus Shot<\/span><\/label><label id=\"forminator-field-checkbox-2-7-69e15d169ea87-label\" for=\"forminator-field-checkbox-2-7-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Hep B Vaccine\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Hep-B-Vaccine\" id=\"forminator-field-checkbox-2-7-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-2-7-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hep B Vaccine<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-69e15d169ea87-label\" class=\"forminator-label\">Preventive Medicine<\/span><label id=\"forminator-field-checkbox-3-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-3-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Pap\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Pap\" id=\"forminator-field-checkbox-3-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-3-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pap<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-3-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Mammogram\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Mammogram\" id=\"forminator-field-checkbox-3-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-3-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Mammogram<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-3-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Prostate Exam\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Prostate-Exam\" id=\"forminator-field-checkbox-3-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-3-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Prostate Exam<\/span><\/label><label id=\"forminator-field-checkbox-3-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-3-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Colonoscopy\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Colonoscopy\" id=\"forminator-field-checkbox-3-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-3-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Colonoscopy<\/span><\/label><label id=\"forminator-field-checkbox-3-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-3-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Not Applicable\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Not-Applicable\" id=\"forminator-field-checkbox-3-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-3-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Not Applicable<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69e15d169ea87-label\" class=\"forminator-label\">Specialists: (seen regularly)<\/span><label id=\"forminator-field-checkbox-4-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cardiologist\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Cardiologist\" id=\"forminator-field-checkbox-4-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cardiologist<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Allergist\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Allergist\" id=\"forminator-field-checkbox-4-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Allergist<\/span><\/label><label id=\"forminator-field-checkbox-4-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Pulmonologist\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Pulmonologist\" id=\"forminator-field-checkbox-4-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pulmonologist<\/span><\/label><label id=\"forminator-field-checkbox-4-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Chiropractor\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Chiropractor\" id=\"forminator-field-checkbox-4-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Chiropractor<\/span><\/label><label id=\"forminator-field-checkbox-4-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 1\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Other-1\" id=\"forminator-field-checkbox-4-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 1<\/span><\/label><label id=\"forminator-field-checkbox-4-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-4-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 2\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Other-2\" id=\"forminator-field-checkbox-4-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-4-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 2<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-5-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-69e15d169ea87-label\" class=\"forminator-label\">Females Only<\/span><label id=\"forminator-field-checkbox-5-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Menopause\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Menopause\" id=\"forminator-field-checkbox-5-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Menopause<\/span><\/label><label id=\"forminator-field-checkbox-5-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Premature Deliveries\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Premature-Deliveries\" id=\"forminator-field-checkbox-5-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Premature Deliveries<\/span><\/label><label id=\"forminator-field-checkbox-5-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Vaginal Deliveries\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Vaginal-Deliveries\" id=\"forminator-field-checkbox-5-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vaginal Deliveries<\/span><\/label><label id=\"forminator-field-checkbox-5-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Full term pregnacies\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Full-term-pregnacies\" id=\"forminator-field-checkbox-5-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Full term pregnacies<\/span><\/label><label id=\"forminator-field-checkbox-5-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"C-Section\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"C-Section\" id=\"forminator-field-checkbox-5-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">C-Section<\/span><\/label><label id=\"forminator-field-checkbox-5-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Miscarriages\/Abortions\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Miscarriages-Abortions\" id=\"forminator-field-checkbox-5-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Miscarriages\/Abortions<\/span><\/label><label id=\"forminator-field-checkbox-5-7-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-7-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure (During Pregnancy)\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"High-Blood-Pressure-(During-Pregnancy)\" id=\"forminator-field-checkbox-5-7-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-7-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure (During Pregnancy)<\/span><\/label><label id=\"forminator-field-checkbox-5-8-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-8-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes (During Pregnancy)\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Diabetes-(During-Pregnancy)\" id=\"forminator-field-checkbox-5-8-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-8-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes (During Pregnancy)<\/span><\/label><label id=\"forminator-field-checkbox-5-9-69e15d169ea87-label\" for=\"forminator-field-checkbox-5-9-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Pre-eclampsia or eclampsia (During Pregnancy)\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Pre-eclampsia-or-eclampsia-(During-Pregnancy)\" id=\"forminator-field-checkbox-5-9-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-5-9-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Pre-eclampsia or eclampsia (During Pregnancy)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-69e15d169ea87-label\" class=\"forminator-label\">Surgical History<\/span><label id=\"forminator-field-checkbox-6-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Tonsillectomy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Tonsillectomy\" id=\"forminator-field-checkbox-6-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tonsillectomy<\/span><\/label><label id=\"forminator-field-checkbox-6-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Bypass\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Heart-Bypass\" id=\"forminator-field-checkbox-6-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Bypass<\/span><\/label><label id=\"forminator-field-checkbox-6-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Thyroid Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Thyroid-Surgery\" id=\"forminator-field-checkbox-6-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thyroid Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Breast Surgery \/ Biopsy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Breast-Surgery---Biopsy\" id=\"forminator-field-checkbox-6-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breast Surgery \/ Biopsy<\/span><\/label><label id=\"forminator-field-checkbox-6-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Vasectomy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Vasectomy\" id=\"forminator-field-checkbox-6-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vasectomy<\/span><\/label><label id=\"forminator-field-checkbox-6-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"C-Section\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"C-Section\" id=\"forminator-field-checkbox-6-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">C-Section<\/span><\/label><label id=\"forminator-field-checkbox-6-7-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-7-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Knee \/ Hip Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Knee---Hip-Surgery\" id=\"forminator-field-checkbox-6-7-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-7-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Knee \/ Hip Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-8-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-8-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Back Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Back-Surgery\" id=\"forminator-field-checkbox-6-8-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-8-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Back Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-9-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-9-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Prostate Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Prostate-Surgery\" id=\"forminator-field-checkbox-6-9-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-9-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Prostate Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-10-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-10-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Gall Bladder Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Gall-Bladder-Surgery\" id=\"forminator-field-checkbox-6-10-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-10-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Gall Bladder Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-11-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-11-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Hernia Repair\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Hernia-Repair\" id=\"forminator-field-checkbox-6-11-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-11-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hernia Repair<\/span><\/label><label id=\"forminator-field-checkbox-6-12-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-12-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Hysterectomy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Hysterectomy\" id=\"forminator-field-checkbox-6-12-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-12-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hysterectomy<\/span><\/label><label id=\"forminator-field-checkbox-6-13-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-13-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Shoulder Surgery\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Shoulder-Surgery\" id=\"forminator-field-checkbox-6-13-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-13-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Shoulder Surgery<\/span><\/label><label id=\"forminator-field-checkbox-6-14-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-14-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Appendectomy\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Appendectomy\" id=\"forminator-field-checkbox-6-14-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-14-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Appendectomy<\/span><\/label><label id=\"forminator-field-checkbox-6-15-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-15-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cataract\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Cataract\" id=\"forminator-field-checkbox-6-15-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-15-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cataract<\/span><\/label><label id=\"forminator-field-checkbox-6-16-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-16-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 1\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Other-1\" id=\"forminator-field-checkbox-6-16-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-16-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 1<\/span><\/label><label id=\"forminator-field-checkbox-6-17-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-17-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 2\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Other-2\" id=\"forminator-field-checkbox-6-17-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-17-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 2<\/span><\/label><label id=\"forminator-field-checkbox-6-18-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-18-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 3\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Other-3\" id=\"forminator-field-checkbox-6-18-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-18-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 3<\/span><\/label><label id=\"forminator-field-checkbox-6-19-69e15d169ea87-label\" for=\"forminator-field-checkbox-6-19-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other 4\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Other-4\" id=\"forminator-field-checkbox-6-19-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-6-19-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other 4<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Family History<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-7\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-7-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-7-69e15d169ea87-label\" class=\"forminator-label\">Mother:<\/span><label id=\"forminator-field-checkbox-7-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-7-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-7-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Cancer\" id=\"forminator-field-checkbox-7-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-7-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-7-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-7-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-7-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-7-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-7-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-7-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-7-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"Other\" id=\"forminator-field-checkbox-7-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-7-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-8-69e15d169ea87-label\" class=\"forminator-label\">Father:<\/span><label id=\"forminator-field-checkbox-8-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-8-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-8-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Cancer\" id=\"forminator-field-checkbox-8-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-8-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-8-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-8-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-8-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-8-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-8-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-8-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-8-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"Other\" id=\"forminator-field-checkbox-8-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-8-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-69e15d169ea87-label\" class=\"forminator-label\">Brothers:<\/span><label id=\"forminator-field-checkbox-9-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-9-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-9-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Cancer\" id=\"forminator-field-checkbox-9-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-9-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-9-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-9-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-9-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-9-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-9-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-9-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-9-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Other\" id=\"forminator-field-checkbox-9-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-9-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-10\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-10-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-69e15d169ea87-label\" class=\"forminator-label\">Sisters:<\/span><label id=\"forminator-field-checkbox-10-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-10-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-10-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Cancer\" id=\"forminator-field-checkbox-10-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-10-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-10-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-10-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-10-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-10-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-10-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-10-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-10-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Other\" id=\"forminator-field-checkbox-10-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-10-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-11\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-11-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-11-69e15d169ea87-label\" class=\"forminator-label\">Children:<\/span><label id=\"forminator-field-checkbox-11-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-11-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-11-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Cancer\" id=\"forminator-field-checkbox-11-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-11-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-11-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-11-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-11-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-11-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-11-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-11-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-11-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Other\" id=\"forminator-field-checkbox-11-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-11-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-12\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-12-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-12-69e15d169ea87-label\" class=\"forminator-label\">Grandfathers<\/span><label id=\"forminator-field-checkbox-12-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-12-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-12-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Cancer\" id=\"forminator-field-checkbox-12-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-12-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-12-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-12-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-12-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-12-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-12-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-12-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-12-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-12[]\" value=\"Other\" id=\"forminator-field-checkbox-12-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-12-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-13\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-13-69e15d169ea87-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-13-69e15d169ea87-label\" class=\"forminator-label\">Grandmothers<\/span><label id=\"forminator-field-checkbox-13-1-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-1-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-13-1-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-1-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-13-2-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-2-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"Cancer\" id=\"forminator-field-checkbox-13-2-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-2-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-13-3-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-3-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Blood Pressure\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"High-Blood-Pressure\" id=\"forminator-field-checkbox-13-3-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-3-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Blood Pressure<\/span><\/label><label id=\"forminator-field-checkbox-13-4-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-4-69e15d169ea87\" class=\"forminator-checkbox\" title=\"High Cholesterol\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"High-Cholesterol\" id=\"forminator-field-checkbox-13-4-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-4-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-13-5-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-5-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Heart Attack\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"Heart-Attack\" id=\"forminator-field-checkbox-13-5-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-5-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack<\/span><\/label><label id=\"forminator-field-checkbox-13-6-69e15d169ea87-label\" for=\"forminator-field-checkbox-13-6-69e15d169ea87\" class=\"forminator-checkbox\" title=\"Other\"><input type=\"checkbox\" name=\"checkbox-13[]\" value=\"Other\" id=\"forminator-field-checkbox-13-6-69e15d169ea87\" aria-labelledby=\"forminator-field-checkbox-13-6-69e15d169ea87-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Other<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Social History<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69e15d169ea87\" id=\"forminator-field-name-3_69e15d169ea87-label\" class=\"forminator-label\">Occupation<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69e15d169ea87\" id=\"forminator-field-name-4_69e15d169ea87-label\" class=\"forminator-label\">Hobbies \/ Activites<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69e15d169ea87-label\"><span id=\"forminator-radiogroup-radio-2-69e15d169ea87-label\" class=\"forminator-label\">Marital Status<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69e15d169ea87\" class=\"forminator-radio\" title=\"Single\"><input type=\"radio\" name=\"radio-2\" value=\"Single\" id=\"forminator-field-radio-2-1-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Single<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69e15d169ea87\" class=\"forminator-radio\" title=\"Married\"><input type=\"radio\" name=\"radio-2\" value=\"Married\" id=\"forminator-field-radio-2-2-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Married<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-69e15d169ea87\" class=\"forminator-radio\" title=\"Widowed\"><input type=\"radio\" name=\"radio-2\" value=\"Widowed\" id=\"forminator-field-radio-2-3-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Widowed<\/span><\/label><label id=\"forminator-field-radio-2-label-4\" for=\"forminator-field-radio-2-4-69e15d169ea87\" class=\"forminator-radio\" title=\"Divorced\"><input type=\"radio\" name=\"radio-2\" value=\"Divorced\" id=\"forminator-field-radio-2-4-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-2-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Divorced<\/span><\/label><label id=\"forminator-field-radio-2-label-5\" for=\"forminator-field-radio-2-5-69e15d169ea87\" class=\"forminator-radio\" title=\"Seperated\"><input type=\"radio\" name=\"radio-2\" value=\"Seperated\" id=\"forminator-field-radio-2-5-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-2-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Seperated<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69e15d169ea87-label\"><span id=\"forminator-radiogroup-radio-3-69e15d169ea87-label\" class=\"forminator-label\">Tobacco<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69e15d169ea87\" class=\"forminator-radio\" title=\"Never\"><input type=\"radio\" name=\"radio-3\" value=\"Never\" id=\"forminator-field-radio-3-1-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Never<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69e15d169ea87\" class=\"forminator-radio\" title=\"Now\"><input type=\"radio\" name=\"radio-3\" value=\"Now\" id=\"forminator-field-radio-3-2-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Now<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-69e15d169ea87\" class=\"forminator-radio\" title=\"Quit\"><input type=\"radio\" name=\"radio-3\" value=\"Quit\" id=\"forminator-field-radio-3-3-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Quit<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-69e15d169ea87-label\"><span id=\"forminator-radiogroup-radio-4-69e15d169ea87-label\" class=\"forminator-label\">Alcohol use:<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69e15d169ea87\" class=\"forminator-radio\" title=\"Never\"><input type=\"radio\" name=\"radio-4\" value=\"Never\" id=\"forminator-field-radio-4-1-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Never<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69e15d169ea87\" class=\"forminator-radio\" title=\"Liquor\"><input type=\"radio\" name=\"radio-4\" value=\"Liquor\" id=\"forminator-field-radio-4-2-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Liquor<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69e15d169ea87\" class=\"forminator-radio\" title=\"Beer\"><input type=\"radio\" name=\"radio-4\" value=\"Beer\" id=\"forminator-field-radio-4-3-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Beer<\/span><\/label><label id=\"forminator-field-radio-4-label-4\" for=\"forminator-field-radio-4-4-69e15d169ea87\" class=\"forminator-radio\" title=\"Wine\"><input type=\"radio\" name=\"radio-4\" value=\"Wine\" id=\"forminator-field-radio-4-4-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-4-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Wine<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-69e15d169ea87-label\"><span id=\"forminator-radiogroup-radio-5-69e15d169ea87-label\" class=\"forminator-label\">Recreational Drug Use:<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69e15d169ea87\" class=\"forminator-radio\" title=\"Never\"><input type=\"radio\" name=\"radio-5\" value=\"Never\" id=\"forminator-field-radio-5-1-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Never<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69e15d169ea87\" class=\"forminator-radio\" title=\"Now\"><input type=\"radio\" name=\"radio-5\" value=\"Now\" id=\"forminator-field-radio-5-2-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Now<\/span><\/label><label id=\"forminator-field-radio-5-label-3\" for=\"forminator-field-radio-5-3-69e15d169ea87\" class=\"forminator-radio\" title=\"In the Past\"><input type=\"radio\" name=\"radio-5\" value=\"In-the-Past\" id=\"forminator-field-radio-5-3-69e15d169ea87\" aria-labelledby=\"forminator-field-radio-5-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">In the Past<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Release of Test Information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69e15d169ea87\" id=\"forminator-field-name-5_69e15d169ea87-label\" class=\"forminator-label\">Patient&#039;s First Name<\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69e15d169ea87\" id=\"forminator-field-name-6_69e15d169ea87-label\" class=\"forminator-label\">Patient&#039;s Last Name<\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69e15d169ea87\" id=\"forminator-field-date-2-picker_69e15d169ea87-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69e15d169ea87\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_69e15d169ea87\" id=\"forminator-field-name-7_69e15d169ea87-label\" class=\"forminator-label\">Patients Name Release Consent<\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"\" id=\"forminator-field-name-7_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-8\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-8\"><h3 class=\"forminator-subtitle\">I  (&nbsp; {name-1}  &nbsp; ) give my consent to the staff At My Best Health, LLC, to relay any lab, radiological testing, referral information or any other imperative information to:<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-8\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-8_69e15d169ea87\" id=\"forminator-field-name-8_69e15d169ea87-label\" class=\"forminator-label\">Name 1:<\/label><input type=\"text\" name=\"name-8\" value=\"\" placeholder=\"\" id=\"forminator-field-name-8_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-9\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-9_69e15d169ea87\" id=\"forminator-field-name-9_69e15d169ea87-label\" class=\"forminator-label\">Relationship 1:<\/label><input type=\"text\" name=\"name-9\" value=\"\" placeholder=\"\" id=\"forminator-field-name-9_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-10\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-10_69e15d169ea87\" id=\"forminator-field-name-10_69e15d169ea87-label\" class=\"forminator-label\">Name 2:<\/label><input type=\"text\" name=\"name-10\" value=\"\" placeholder=\"\" id=\"forminator-field-name-10_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-11\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-11_69e15d169ea87\" id=\"forminator-field-name-11_69e15d169ea87-label\" class=\"forminator-label\">Relationship 2:<\/label><input type=\"text\" name=\"name-11\" value=\"\" placeholder=\"\" id=\"forminator-field-name-11_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69e15d169ea87\" id=\"forminator-field-phone-3_69e15d169ea87-label\" class=\"forminator-label\">Answering Machine at Home: Tel No.<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_69e15d169ea87\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_69e15d169ea87\" id=\"forminator-field-phone-4_69e15d169ea87-label\" class=\"forminator-label\">Myself, at place of employment: Tel No.<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-4_69e15d169ea87\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Insurance Assignments<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-12\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-12_69e15d169ea87\" id=\"forminator-field-name-12_69e15d169ea87-label\" class=\"forminator-label\">Patient&#039;s First Name<\/label><input type=\"text\" name=\"name-12\" value=\"\" placeholder=\"\" id=\"forminator-field-name-12_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-13\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-13_69e15d169ea87\" id=\"forminator-field-name-13_69e15d169ea87-label\" class=\"forminator-label\">Patient&#039;s Last Name<\/label><input type=\"text\" name=\"name-13\" value=\"\" placeholder=\"\" id=\"forminator-field-name-13_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69e15d169ea87\" id=\"forminator-field-date-3-picker_69e15d169ea87-label\" class=\"forminator-label\">Date of Birth Month<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_69e15d169ea87\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-5\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-5_69e15d169ea87\" id=\"forminator-field-phone-5_69e15d169ea87-label\" class=\"forminator-label\">Phone Number:<\/label><input type=\"text\" name=\"phone-5\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-5_69e15d169ea87\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p>As you are aware, healthcare in the United States is currently undergoing many changes. As a result, insurance carriers are becoming more selective in terms of what they deem \u201cnecessary care\u201d or \u201ccovered care\u201d. At My Best Health, LLC, we believe care is essential to your health and therefore will continue to offer a thorough evaluation to every one of our patients.<\/p>\n<p>Although we try hard, it is not always possible to verify all the terms of every patient\u2019s insurance plan to determine if care is a covered benefit. We are informing you in advance that some tests and\/or procedures, although constituting good medical care, may be considered as screening or preventive in nature by some insurance companies, and thus not covered. This testing will be your financial obligation if denied by your insurance carrier. We advise that all of our patients review their insurance benefit coverage. We will continue to do what we can to help in this respect.<\/p>\n<p>Please list the insurance company (ies) that you will be using for services At My Best&nbsp;Health, LLC:<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-14\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-14_69e15d169ea87\" id=\"forminator-field-name-14_69e15d169ea87-label\" class=\"forminator-label\">Insurance Company 1:<\/label><span id=\"forminator-field-name-14_69e15d169ea87-description\" class=\"forminator-description\">ID and Group number required<\/span><input type=\"text\" name=\"name-14\" value=\"\" placeholder=\"\" id=\"forminator-field-name-14_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" aria-describedby=\"forminator-field-name-14_69e15d169ea87-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-15\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-15_69e15d169ea87\" id=\"forminator-field-name-15_69e15d169ea87-label\" class=\"forminator-label\">Insurance Company 2:<\/label><span id=\"forminator-field-name-15_69e15d169ea87-description\" class=\"forminator-description\">ID and Group number required<\/span><input type=\"text\" name=\"name-15\" value=\"\" placeholder=\"\" id=\"forminator-field-name-15_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" aria-describedby=\"forminator-field-name-15_69e15d169ea87-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-16\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-16_69e15d169ea87\" id=\"forminator-field-name-16_69e15d169ea87-label\" class=\"forminator-label\">Insurance Company 3:<\/label><span id=\"forminator-field-name-16_69e15d169ea87-description\" class=\"forminator-description\">ID and Group number required<\/span><input type=\"text\" name=\"name-16\" value=\"\" placeholder=\"\" id=\"forminator-field-name-16_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" aria-describedby=\"forminator-field-name-16_69e15d169ea87-description\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p>I, the undersigned, certify that I (or my dependent) have insurance coverage with the insurance company(ies) listed above and assign directly to At My Best Health, LLC, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, and that it is my sole responsibility to understand the insurance benefits that apply. I authorize the use of this signature on all insurance submissions.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-17\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-17_69e15d169ea87\" id=\"forminator-field-name-17_69e15d169ea87-label\" class=\"forminator-label\">Responsible Person:<\/label><input type=\"text\" name=\"name-17\" value=\"\" placeholder=\"\" id=\"forminator-field-name-17_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"name-18\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-18_69e15d169ea87\" id=\"forminator-field-name-18_69e15d169ea87-label\" class=\"forminator-label\">Relationship to patient:<\/label><input type=\"text\" name=\"name-18\" value=\"\" placeholder=\"\" id=\"forminator-field-name-18_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69e15d169ea87\" id=\"forminator-field-date-4-picker_69e15d169ea87-label\" class=\"forminator-label\">Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_69e15d169ea87\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Health Consent Form<\/h2><h3 class=\"forminator-subtitle\">Patient Consent for Use and Disclosure of Protected Health Information<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><p>I hereby give my consent for At My Best Health, LLC, to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by At My Best Health, LLC, describes such uses and disclosures more completely.)<\/p>\n<p>I have the right to review the Notice of Privacy Practices prior to signing this consent. At My Best Health, LLC, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:<\/p>\n<p>At My Best Health, LLC, 18325 N. Allied Way, Phoenix, AZ 85054.<\/p>\n<p>With this consent, At My Best Health, LLC, may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.<\/p>\n<p>With this consent, At My Best Health, LLC, may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.<\/p>\n<p>With this consent, At My Best Health, LLC, may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that At My Best Health, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.<\/p>\n<p>By signing this form, I am consenting to allow At My Best Health, LLC, to use and disclose my PHI to carry out TPO.<\/p>\n<p>I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-19\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-19_69e15d169ea87\" id=\"forminator-field-name-19_69e15d169ea87-label\" class=\"forminator-label\">Patients Name:<\/label><input type=\"text\" name=\"name-19\" value=\"\" placeholder=\"\" id=\"forminator-field-name-19_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_69e15d169ea87\" id=\"forminator-field-date-5-picker_69e15d169ea87-label\" class=\"forminator-label\">Date:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-5-picker_69e15d169ea87\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-20\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-20_69e15d169ea87\" id=\"forminator-field-name-20_69e15d169ea87-label\" class=\"forminator-label\">Legal Guardian:<\/label><span id=\"forminator-field-name-20_69e15d169ea87-description\" class=\"forminator-description\">(if applicable)<\/span><input type=\"text\" name=\"name-20\" value=\"\" placeholder=\"\" id=\"forminator-field-name-20_69e15d169ea87\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" aria-describedby=\"forminator-field-name-20_69e15d169ea87-description\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Form<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"0f20ec3955\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/atmybesthealth.com\/wp-json\/wp\/v2\/pages\/1232\" \/><input type=\"hidden\" name=\"form_id\" value=\"1228\"><input type=\"hidden\" name=\"page_id\" value=\"1232\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/beta10.technodreamcenter.com\/atmybesthealth.com\/new-patient-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/p>\t\t\t\t\t\t\t\t<\/div>\n\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>New Patient 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