{"id":321,"date":"2018-03-27T13:05:08","date_gmt":"2018-03-27T17:05:08","guid":{"rendered":"https:\/\/maxillomauricie.com\/questionnaire-medicale\/"},"modified":"2023-02-09T10:34:36","modified_gmt":"2023-02-09T15:34:36","slug":"medical-form","status":"publish","type":"page","link":"https:\/\/maxillomauricie.com\/en\/new-patients\/medical-form\/","title":{"rendered":"Medical form"},"content":{"rendered":"<section class=\"l-section wpb_row height_huge with_img parallax_ver\"><div class=\"l-section-img\" role=\"img\" aria-label=\"Image\" data-img-width=\"1920\" data-img-height=\"1080\" style=\"background-image: url(https:\/\/maxillomauricie.com\/wp-content\/uploads\/2018\/05\/questionnaire-medical-blackwhite-1.jpg);\"><\/div><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:300px\"><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_huge\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"g-cols wpb_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-2 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:32px\"><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-8 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h1 style=\"text-align: center;\">MEDICAL FORM<\/h1>\n<\/div><\/div><div class=\"w-separator size_small with_line width_30 thick_1 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><div data-uniq='69ef810758bc6' class='uniq-69ef810758bc6 formcraft-css form-live align-left'><style type='text\/css' scoped='scoped'>.powered-by {\ndisplay: none !important;\n}<\/style><script> window.formcraftLogic = window.formcraftLogic || {}; window.formcraftLogic[8] = [[[[\"field76\",\"equal_to\",\"Yes\"]],[[\"show_fields\",\"field81,field82\"]],\"and\"]]; <\/script><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination width-100\">\n\t\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-8 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: none !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title\n\t\t\t{\n\t\t\t\tbackground: #e4c2a7;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #e4c2a7;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c8aa92;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c8aa92;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #e4c2a7;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #e4c2a7;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c8aa92;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-8.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form .final-success .final-success-check {\n\t\t\t\tborder: 2px solid #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .time-fields-cover,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .awesomplete ul\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"radio\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"checkbox\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #ffffff;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"radio\"]:checked,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"checkbox\"]:checked {\n\t\t\t\tborder-color: #c8aa92;\n\t\t\t\tbackground: #e4c2a7;\t\t\t\t\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c8aa92;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c8aa92 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .fileupload-cover .button-file\n\t\t\t{\n\t\t\t\tborder-color: #c8aa92;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #e4c2a7;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: none;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-auto-scroll=\"\" data-no-message-redirect=\"\" data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"8\" class=\"fc-form fc-form-8 align- fc-temp-class save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-placeholder field-border-visible frame-hidden field-alignment-left  \" style=\"width: 99%px; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content      ng-not-empty\">\n\t\t\t\t\t\t<div data-identifier=\"field1\" data-index=\"0\" style=\"width: 50%\" class=\" form-element form-element-field1 options-false form-element-0 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Name of patient<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Name of patient\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"1\" style=\"width: 50%\" class=\" even form-element form-element-field2 options-false form-element-1 default-false form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >File number<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"File number\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-folder\">folder<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"2\" style=\"width: 50%\" class=\" form-element form-element-field3 options-false form-element-2 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >First name of patient<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"First name of patient\" make-read-only=\"false\" data-field-id=\"field3\" name=\"field3[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"3\" style=\"width: 50%\" class=\" even form-element form-element-field4 options-false form-element-3 default-false form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Sex<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Sex\" make-read-only=\"false\" data-field-id=\"field4\" name=\"field4[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field5\" data-index=\"4\" style=\"width: 50%\" class=\" form-element form-element-field5 options-false form-element-4 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Telephone<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Telephone\" make-read-only=\"false\" data-field-id=\"field5\" name=\"field5[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field80\" data-index=\"5\" style=\"width: 50%\" class=\" even form-element form-element-field80 options-false form-element-5 default-false form-element-type-email is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"email-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Email<\/span><\/span><span class=\"sub-label\"><span >a valid email<\/span><\/span><\/span><div><span class=\"error\"><\/span><input placeholder=\"Email\" data-field-id=\"field80\" type=\"text\" data-val-type=\"email\" make-read-only=\"\" data-is-required=\"true\" name=\"field80\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">email<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field6\" data-index=\"6\" style=\"width: 100%\" class=\" form-element form-element-field6 options-false form-element-6 default-false form-element-type-oneLineText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Adress<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Adress\" make-read-only=\"false\" data-field-id=\"field6\" name=\"field6[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field8\" data-index=\"7\" style=\"width: 50%\" class=\" even form-element form-element-field8 options-false form-element-7 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Town<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Town\" make-read-only=\"false\" data-field-id=\"field8\" name=\"field8[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field9\" data-index=\"8\" style=\"width: 50%\" class=\" form-element form-element-field9 options-false form-element-8 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Postal Code<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Postal Code\" make-read-only=\"false\" data-field-id=\"field9\" name=\"field9[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field10\" data-index=\"9\" style=\"width: 100%\" class=\" even form-element form-element-field10 options-false form-element-9 default-false form-element-type-datepicker is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Birth date<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field10\" placeholder=\"Birth date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"true\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"dd\/mm\/yy\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"fr-CA\" name=\"field10\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field11\" data-index=\"10\" style=\"width: 100%\" class=\" form-element form-element-field11 options-false form-element-10 default-false form-element-type-oneLineText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Occupation<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Occupation\" make-read-only=\"false\" data-field-id=\"field11\" name=\"field11[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field12\" data-index=\"11\" style=\"width: 50%\" class=\" even form-element form-element-field12 options-false form-element-11 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Assurance maladie card number<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Assurance maladie card number\" make-read-only=\"false\" data-field-id=\"field12\" name=\"field12[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-payment\">payment<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field13\" data-index=\"12\" style=\"width: 50%\" class=\" form-element form-element-field13 options-false form-element-12 default-false form-element-type-datepicker is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Expiration date<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field13\" placeholder=\"Expiration date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"true\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"dd\/mm\/yy\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"en\" name=\"field13\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"13\" style=\"width: 100%\" class=\" even form-element form-element-field14 options-false form-element-13 default-false form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Family physician name<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Family physician name\" make-read-only=\"false\" data-field-id=\"field14\" name=\"field14[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field15\" data-index=\"14\" style=\"width: 100%\" class=\" form-element form-element-field15 options-false form-element-14 default-false form-element-type-oneLineText is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Dentist name<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Dentist name\" make-read-only=\"false\" data-field-id=\"field15\" name=\"field15[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field16\" data-index=\"15\" style=\"width: 100%\" class=\" even form-element form-element-field16 options-false form-element-15 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Weight<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Weight\" make-read-only=\"false\" data-field-id=\"field16\" name=\"field16[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field17\" data-index=\"16\" style=\"width: 100%\" class=\" form-element form-element-field17 options-false form-element-16 default-false form-element-type-oneLineText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Name, adress and telephone number pharmacy<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Name, adress and telephone number pharmacy\" make-read-only=\"false\" data-field-id=\"field17\" name=\"field17[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field30\" data-index=\"17\" style=\"width: 100%\" class=\" even form-element form-element-field30 options-false form-element-17 default-false form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field30\" data-field-id=\"field30\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field18\" data-index=\"18\" style=\"width: 100%\" class=\" form-element form-element-field18 options-false form-element-18 default-false form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >Please answer all questions<\/p><\/div><input type=\"hidden\" name=\"field18\" data-field-id=\"field18\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field19\" data-index=\"19\" style=\"width: 100%\" class=\" even form-element form-element-field19 options-false form-element-19 default-false form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Have you ever taken the following medications :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"&lt;b&gt;No medication\" class=\"validation-lenient\"><span><b >No medication<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Actonel\" class=\"validation-lenient\"><span><span >Actonel<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Fosamax\" class=\"validation-lenient\"><span><span >Fosamax<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Xgeva\" class=\"validation-lenient\"><span><span >Xgeva<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Prolia\" class=\"validation-lenient\"><span><span >Prolia<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Alendronate\" class=\"validation-lenient\"><span><span >Alendronate<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Anovulant\" class=\"validation-lenient\"><span><span >Anovulant<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Aspirine\" class=\"validation-lenient\"><span><span >Aspirine<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"ASA\" class=\"validation-lenient\"><span><span >ASA<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Brillinta\" class=\"validation-lenient\"><span><span >Brillinta<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Coumadin\" class=\"validation-lenient\"><span><span >Coumadin<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Cod\u00e9ine\" class=\"validation-lenient\"><span><span >Cod\u00e9ine<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Emtec\" class=\"validation-lenient\"><span><span >Emtec<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Empracet\" class=\"validation-lenient\"><span><span >Empracet<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Cortisone\" class=\"validation-lenient\"><span><span >Cortisone<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Eliquis\" class=\"validation-lenient\"><span><span >Eliquis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Entrophen\" class=\"validation-lenient\"><span><span >Entrophen<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Plavix\" class=\"validation-lenient\"><span><span >Plavix<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Pradaxa\" class=\"validation-lenient\"><span><span >Pradaxa<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field19\" type=\"checkbox\" data-is-required=\"true\" name=\"field19[]\" value=\"Xarelto\" class=\"validation-lenient\"><span><span >Xarelto<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field83\" data-index=\"20\" style=\"width: 100%\" class=\" form-element form-element-field83 form-element-20 default-false form-element-type-checkbox is-required-false odd -handle options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Are you currently taking a medication for diabetes or weight loss that is a GLP-1 receptor agonist (e.g., Ozempic, Wegovy, or other similar medications)?<\/span><\/span><span class=\"sub-label\"><span >choisissez-en un!<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field83\" type=\"checkbox\" data-is-required=\"false\" name=\"field83[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field83\" type=\"checkbox\" data-is-required=\"false\" name=\"field83[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field20\" data-index=\"21\" style=\"width: 100%\" class=\" form-element form-element-field20 options-false default-false form-element-type-checkbox is-required-true even form-element-21 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Are you actually taking other medication or natural products ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field20\" type=\"radio\" data-is-required=\"true\" name=\"field20[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field20\" type=\"radio\" data-is-required=\"true\" name=\"field20[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field21\" data-index=\"22\" style=\"width: 100%\" class=\" form-element form-element-field21 options-false default-false form-element-type-textarea is-required-false odd form-element-22 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Join a list of medication<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field21\" placeholder=\"Join a list of medication\" class=\"validation-lenient\" name=\"field21\" value=\"\" rows=\"5\" data-min-char=\"\" data-max-char=\"\" data-is-required=\"false\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 110.734375px\"><\/textarea><div class=\"count-\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \"><\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field22\" data-index=\"23\" style=\"width: 100%\" class=\" form-element form-element-field22 options-false default-false form-element-type-checkbox is-required-true even form-element-23 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >In the eventuallity of a surgery in the opereting room at the hospital, is there any question\/preoccupation you would like to discuss with the anestheologist prior to the surgery ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field22\" type=\"radio\" data-is-required=\"true\" name=\"field22[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field22\" type=\"radio\" data-is-required=\"true\" name=\"field22[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field32\" data-index=\"24\" style=\"width: 100%\" class=\" form-element form-element-field32 options-false default-false form-element-type-customText is-required-false odd form-element-24 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field32\" data-field-id=\"field32\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field23\" data-index=\"25\" style=\"width: 100%\" class=\" form-element form-element-field23 options-false default-false form-element-type-customText is-required-false even form-element-25 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >Have you been or are you actually treated for one or many of these conditions :<\/p><\/div><input type=\"hidden\" name=\"field23\" data-field-id=\"field23\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field25\" data-index=\"26\" style=\"width: 100%\" class=\" form-element form-element-field25 options-false default-false form-element-type-checkbox is-required-true odd form-element-26 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Cardiologic problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"&lt;b&gt; No cardiologic problem\" class=\"validation-lenient\"><span><b > No cardiologic problem<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Heart attack\" class=\"validation-lenient\"><span><span >Heart attack<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Hypertension \" class=\"validation-lenient\"><span><span >Hypertension <\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Arythmia\" class=\"validation-lenient\"><span><span >Arythmia<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Chest pain\" class=\"validation-lenient\"><span><span >Chest pain<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Stroke or paralysis\" class=\"validation-lenient\"><span><span >Stroke or paralysis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Valvular problem\/cardiac murmur\" class=\"validation-lenient\"><span><span >Valvular problem\/cardiac murmur<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Endocarditis\" class=\"validation-lenient\"><span><span >Endocarditis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Rhumatismal fever\" class=\"validation-lenient\"><span><span >Rhumatismal fever<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Cardiac malformation\" class=\"validation-lenient\"><span><span >Cardiac malformation<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Cardiac stent or bipass\" class=\"validation-lenient\"><span><span >Cardiac stent or bipass<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"checkbox\" data-is-required=\"true\" name=\"field25[]\" value=\"Pacemaker\" class=\"validation-lenient\"><span><span >Pacemaker<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field26\" data-index=\"27\" style=\"width: 100%\" class=\" form-element form-element-field26 options-false default-false form-element-type-datepicker is-required-false even form-element-27 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If heart attack, indicate date<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field26\" placeholder=\"If heart attack, indicate date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"false\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"yy-mm-dd\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"en\" name=\"field26\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field27\" data-index=\"28\" style=\"width: 100%\" class=\" form-element form-element-field27 options-false default-false form-element-type-oneLineText is-required-false odd form-element-28 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If cardiac malformation, indicate type<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If cardiac malformation, indicate type\" make-read-only=\"false\" data-field-id=\"field27\" name=\"field27[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field28\" data-index=\"29\" style=\"width: 100%\" class=\" form-element form-element-field28 options-false default-false form-element-type-datepicker is-required-false even form-element-29 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If cardiac stent\/bipass, indicate date<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field28\" placeholder=\"If cardiac stent\/bipass, indicate date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"false\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"yy-mm-dd\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"en\" name=\"field28\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field37\" data-index=\"30\" style=\"width: 100%\" class=\" form-element form-element-field37 options-false default-false form-element-type-customText is-required-false odd form-element-30 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field37\" data-field-id=\"field37\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field34\" data-index=\"31\" style=\"width: 100%\" class=\" form-element form-element-field34 options-false default-false form-element-type-checkbox is-required-true even form-element-31 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Bleeding disorder :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"&lt;b&gt; No bleeding disorder\" class=\"validation-lenient\"><span><b > No bleeding disorder<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Frequent bruising\" class=\"validation-lenient\"><span><span >Frequent bruising<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Spontaneous bleeding\" class=\"validation-lenient\"><span><span >Spontaneous bleeding<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Prolong bleeding\" class=\"validation-lenient\"><span><span >Prolong bleeding<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Blood transfusion\" class=\"validation-lenient\"><span><span >Blood transfusion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Hemophilia\" class=\"validation-lenient\"><span><span >Hemophilia<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Von Willebrand disease\" class=\"validation-lenient\"><span><span >Von Willebrand disease<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Leg varix\" class=\"validation-lenient\"><span><span >Leg varix<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Thrombophlebitis\" class=\"validation-lenient\"><span><span >Thrombophlebitis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"checkbox\" data-is-required=\"true\" name=\"field34[]\" value=\"Pulmonary embolism\" class=\"validation-lenient\"><span><span >Pulmonary embolism<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field53\" data-index=\"32\" style=\"width: 100%\" class=\" form-element form-element-field53 options-false default-false form-element-type-customText is-required-false odd form-element-32 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field53\" data-field-id=\"field53\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field36\" data-index=\"33\" style=\"width: 100%\" class=\" form-element form-element-field36 options-false default-false form-element-type-checkbox is-required-true even form-element-33 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Infection problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"&lt;b&gt;No infection problem\" class=\"validation-lenient\"><span><b >No infection problem<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"AIDS or HIV\" class=\"validation-lenient\"><span><span >AIDS or HIV<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"Tuberculosis\" class=\"validation-lenient\"><span><span >Tuberculosis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"Labial herpes\" class=\"validation-lenient\"><span><span >Labial herpes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"Hepatitis\" class=\"validation-lenient\"><span><span >Hepatitis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field36\" type=\"checkbox\" data-is-required=\"true\" name=\"field36[]\" value=\"STD (sexually transmissible diseases)\" class=\"validation-lenient\"><span><span >STD (sexually transmissible diseases)<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field31\" data-index=\"34\" style=\"width: 100%\" class=\" form-element form-element-field31 options-false default-false form-element-type-customText is-required-false odd form-element-34 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field31\" data-field-id=\"field31\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field39\" data-index=\"35\" style=\"width: 100%\" class=\" form-element form-element-field39 options-false default-false form-element-type-checkbox is-required-true even form-element-35 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Endocrinologic problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field39\" type=\"checkbox\" data-is-required=\"true\" name=\"field39[]\" value=\"&lt;b&gt;No endocrinologic problem\" class=\"validation-lenient\"><span><b >No endocrinologic problem<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field39\" type=\"checkbox\" data-is-required=\"true\" name=\"field39[]\" value=\"Diabetes\" class=\"validation-lenient\"><span><span >Diabetes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field39\" type=\"checkbox\" data-is-required=\"true\" name=\"field39[]\" value=\"Hypothyridism\" class=\"validation-lenient\"><span><span >Hypothyridism<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field40\" data-index=\"36\" style=\"width: 100%\" class=\" form-element form-element-field40 options-false default-false form-element-type-customText is-required-false odd form-element-36 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field40\" data-field-id=\"field40\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field42\" data-index=\"37\" style=\"width: 100%\" class=\" form-element form-element-field42 options-false default-false form-element-type-checkbox is-required-true even form-element-37 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Hepatologic\/digestive problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"&lt;b&gt; No hepatologic\/digestive problem\" class=\"validation-lenient\"><span><b > No hepatologic\/digestive problem<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Cirrhosis\" class=\"validation-lenient\"><span><span >Cirrhosis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Jaundice\" class=\"validation-lenient\"><span><span >Jaundice<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Heart burn (reflux)\" class=\"validation-lenient\"><span><span >Heart burn (reflux)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Hepatitis\" class=\"validation-lenient\"><span><span >Hepatitis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Gastric Ulcer\" class=\"validation-lenient\"><span><span >Gastric Ulcer<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"checkbox\" data-is-required=\"true\" name=\"field42[]\" value=\"Inflammatory bowel disease (Crohn disease, ulcerative colitis)\" class=\"validation-lenient\"><span><span >Inflammatory bowel disease (Crohn disease, ulcerative colitis)<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field44\" data-index=\"38\" style=\"width: 100%\" class=\" form-element form-element-field44 options-false default-false form-element-type-customText is-required-false odd form-element-38 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field44\" data-field-id=\"field44\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field46\" data-index=\"39\" style=\"width: 100%\" class=\" form-element form-element-field46 options-false default-false form-element-type-checkbox is-required-true even form-element-39 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Neurologic problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"checkbox\" data-is-required=\"true\" name=\"field46[]\" value=\"&lt;b&gt; No neurologic problem :\" class=\"validation-lenient\"><span><b > No neurologic problem :<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"checkbox\" data-is-required=\"true\" name=\"field46[]\" value=\"Epilepsia ou convulsion\" class=\"validation-lenient\"><span><span >Epilepsia ou convulsion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"checkbox\" data-is-required=\"true\" name=\"field46[]\" value=\"Multiple sclerosis\" class=\"validation-lenient\"><span><span >Multiple sclerosis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"checkbox\" data-is-required=\"true\" name=\"field46[]\" value=\"Depression\" class=\"validation-lenient\"><span><span >Depression<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"checkbox\" data-is-required=\"true\" name=\"field46[]\" value=\"Mental health problem\" class=\"validation-lenient\"><span><span >Mental health problem<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field47\" data-index=\"40\" style=\"width: 100%\" class=\" form-element form-element-field47 options-false default-false form-element-type-oneLineText is-required-false odd form-element-40 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If mental health problem, indicate diagnostic&nbsp;:<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If mental health problem, indicate diagnostic&nbsp;:\" make-read-only=\"false\" data-field-id=\"field47\" name=\"field47[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field48\" data-index=\"41\" style=\"width: 100%\" class=\" form-element form-element-field48 options-false default-false form-element-type-customText is-required-false even form-element-41 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field48\" data-field-id=\"field48\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field50\" data-index=\"42\" style=\"width: 100%\" class=\" form-element form-element-field50 options-false default-false form-element-type-checkbox is-required-true odd form-element-42 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Oncologic problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field50\" type=\"checkbox\" data-is-required=\"true\" name=\"field50[]\" value=\"&lt;b&gt; No oncologic problem :\" class=\"validation-lenient\"><span><b > No oncologic problem :<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field50\" type=\"checkbox\" data-is-required=\"true\" name=\"field50[]\" value=\"Cancer\" class=\"validation-lenient\"><span><span >Cancer<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field50\" type=\"checkbox\" data-is-required=\"true\" name=\"field50[]\" value=\"Radiotherapy\" class=\"validation-lenient\"><span><span >Radiotherapy<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field50\" type=\"checkbox\" data-is-required=\"true\" name=\"field50[]\" value=\"Chemotherapy\" class=\"validation-lenient\"><span><span >Chemotherapy<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field51\" data-index=\"43\" style=\"width: 50%\" class=\" form-element form-element-field51 options-false default-false form-element-type-oneLineText is-required-false even form-element-43 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If cancer, indicate type&nbsp;:<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If cancer, indicate type&nbsp;:\" make-read-only=\"false\" data-field-id=\"field51\" name=\"field51[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field52\" data-index=\"44\" style=\"width: 50%\" class=\" form-element form-element-field52 options-false default-false form-element-type-oneLineText is-required-false odd form-element-44 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If radiotherapy, indicate :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If radiotherapy, indicate :\" make-read-only=\"false\" data-field-id=\"field52\" name=\"field52[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field54\" data-index=\"45\" style=\"width: 100%\" class=\" form-element form-element-field54 options-false default-false form-element-type-customText is-required-false even form-element-45 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field54\" data-field-id=\"field54\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field56\" data-index=\"46\" style=\"width: 100%\" class=\" form-element form-element-field56 options-false default-false form-element-type-checkbox is-required-true odd form-element-46 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Pulmonary problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"&lt;b&gt; No pulmonary problem\" class=\"validation-lenient\"><span><b > No pulmonary problem<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Chronic bronchitis (COPD)\" class=\"validation-lenient\"><span><span >Chronic bronchitis (COPD)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Asthma\" class=\"validation-lenient\"><span><span >Asthma<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Sleep apnea\" class=\"validation-lenient\"><span><span >Sleep apnea<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field57\" data-index=\"47\" style=\"width: 100%\" class=\" form-element form-element-field57 options-false default-false form-element-type-customText is-required-false even form-element-47 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field57\" data-field-id=\"field57\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field59\" data-index=\"48\" style=\"width: 100%\" class=\" form-element form-element-field59 options-false default-false form-element-type-checkbox is-required-true odd form-element-48 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Renal problem :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"&lt;b&gt; No renal problem \" class=\"validation-lenient\"><span><b > No renal problem <\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Renal failure\" class=\"validation-lenient\"><span><span >Renal failure<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Dialysis\" class=\"validation-lenient\"><span><span >Dialysis<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field60\" data-index=\"49\" style=\"width: 100%\" class=\" form-element form-element-field60 options-false default-false form-element-type-customText is-required-false even form-element-49 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field60\" data-field-id=\"field60\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field62\" data-index=\"50\" style=\"width: 100%\" class=\" form-element form-element-field62 options-false default-false form-element-type-checkbox is-required-true odd form-element-50 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Other problems<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"&lt;b&gt; No other problems\" class=\"validation-lenient\"><span><b > No other problems<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Facial trauma\" class=\"validation-lenient\"><span><span >Facial trauma<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Are-you pregnant?\" class=\"validation-lenient\"><span><span >Are-you pregnant?<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Bad scaring (Cheloid)\" class=\"validation-lenient\"><span><span >Bad scaring (Cheloid)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Hay fever\" class=\"validation-lenient\"><span><span >Hay fever<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field63\" data-index=\"51\" style=\"width: 100%\" class=\" form-element form-element-field63 options-false default-false form-element-type-oneLineText is-required-false even form-element-51 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If pregnant, how many weeks :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If pregnant, how many weeks :\" make-read-only=\"false\" data-field-id=\"field63\" name=\"field63[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field64\" data-index=\"52\" style=\"width: 100%\" class=\" form-element form-element-field64 options-false default-false form-element-type-oneLineText is-required-false odd form-element-52 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Other medical condition :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Other medical condition :\" make-read-only=\"false\" data-field-id=\"field64\" name=\"field64[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field65\" data-index=\"53\" style=\"width: 100%\" class=\" form-element form-element-field65 options-false default-false form-element-type-oneLineText is-required-false even form-element-53 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Past surgeries :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Past surgeries :\" make-read-only=\"false\" data-field-id=\"field65\" name=\"field65[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field67\" data-index=\"54\" style=\"width: 100%\" class=\" form-element form-element-field67 options-false default-false form-element-type-customText is-required-false odd form-element-54 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field67\" data-field-id=\"field67\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field66\" data-index=\"55\" style=\"width: 100%\" class=\" form-element form-element-field66 options-false default-false form-element-type-checkbox is-required-true even form-element-55 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Are you allergic to :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"&lt;b&gt; No allergies\" class=\"validation-lenient\"><span><b > No allergies<\/b><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"ASPIRINE\" class=\"validation-lenient\"><span><span >ASPIRINE<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"CODEINE\" class=\"validation-lenient\"><span><span >CODEINE<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"PENICILLIN\" class=\"validation-lenient\"><span><span >PENICILLIN<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"LOCAL ANESTHESIA\" class=\"validation-lenient\"><span><span >LOCAL ANESTHESIA<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"LATEX\" class=\"validation-lenient\"><span><span >LATEX<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"IODINE\" class=\"validation-lenient\"><span><span >IODINE<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field66\" type=\"checkbox\" data-is-required=\"true\" name=\"field66[]\" value=\"OTHER\" class=\"validation-lenient\"><span><span >OTHER<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field68\" data-index=\"56\" style=\"width: 100%\" class=\" form-element form-element-field68 options-false default-false form-element-type-oneLineText is-required-false odd form-element-56 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Other allergies :<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Other allergies :\" make-read-only=\"false\" data-field-id=\"field68\" name=\"field68[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field69\" data-index=\"57\" style=\"width: 100%\" class=\" form-element form-element-field69 options-false default-false form-element-type-customText is-required-false even form-element-57 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field69\" data-field-id=\"field69\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field71\" data-index=\"58\" style=\"width: 100%\" class=\" form-element form-element-field71 options-false default-false form-element-type-customText is-required-false odd form-element-58 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >Are you using :<span id=\"selectionBoundary_1525201354520_7980278136945287\" class=\"rangySelectionBoundary\">\ufeff<\/span><span id=\"selectionBoundary_1525201350589_9953127518594245\" class=\"rangySelectionBoundary\">\ufeff<\/span><span id=\"selectionBoundary_1525201344430_6900581683588801\" class=\"rangySelectionBoundary\">\ufeff<\/span><\/p><\/div><input type=\"hidden\" name=\"field71\" data-field-id=\"field71\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field70\" data-index=\"59\" style=\"width: 100%\" class=\" form-element form-element-field70 options-false default-false form-element-type-matrix is-required-true even form-element-59 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"matrix-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Habits<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><table cellspacing=\"0\" cellpadding=\"0\"><thead><tr><th><\/th><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Regularly<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Occasionnely<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Never<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><\/thead><tbody><!-- ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >Tabacco<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_0\" value=\"Regularly\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_0\" value=\"Occasionnely\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_0\" value=\"Never\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >Alcohol<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_1\" value=\"Regularly\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_1\" value=\"Occasionnely\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_1\" value=\"Never\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >Drugs<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_2\" value=\"Regularly\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_2\" value=\"Occasionnely\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field70_2\" value=\"Never\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><\/tbody><\/table><\/div><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field72\" data-index=\"60\" style=\"width: 100%\" class=\" form-element form-element-field72 options-false default-false form-element-type-oneLineText is-required-false odd form-element-60 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If yes, nbr\/day<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If yes, nbr\/day\" make-read-only=\"false\" data-field-id=\"field72\" name=\"field72[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field75\" data-index=\"61\" style=\"width: 100%\" class=\" form-element form-element-field75 options-false default-false form-element-type-customText is-required-false even form-element-61 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><hr ><\/div><input type=\"hidden\" name=\"field75\" data-field-id=\"field75\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field76\" data-index=\"62\" style=\"width: 100%\" class=\" form-element form-element-field76 options-false default-false form-element-type-checkbox is-required-true odd form-element-62 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Do you fear dental treatment ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"radio\" data-is-required=\"true\" name=\"field76[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"radio\" data-is-required=\"true\" name=\"field76[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field81\" data-index=\"63\" style=\"width: 100%\" class=\" form-element form-element-field81 options-false default-true form-element-type-matrix is-required-false even form-element-63 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"matrix-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Anxiety questions<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><table cellspacing=\"0\" cellpadding=\"0\"><thead><tr><th><\/th><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Not anxious at all (1)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Slightly anxious (2)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Fairly anxious (3)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Very anxious (4)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Extremely anxious (5)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><\/thead><tbody><!-- ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >If you were going to the dentist for treatment tomorrow, how would you feel?<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_0\" value=\"Not anxious at all (1)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_0\" value=\"Slightly anxious (2)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_0\" value=\"Fairly anxious (3)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_0\" value=\"Very anxious (4)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_0\" value=\"Extremely anxious (5)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >If you were sitting in the waiting room waiting for your treatment, how would you feel?<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_1\" value=\"Not anxious at all (1)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_1\" value=\"Slightly anxious (2)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_1\" value=\"Fairly anxious (3)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_1\" value=\"Very anxious (4)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_1\" value=\"Extremely anxious (5)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >If you were about to have a filling done, how would you feel?<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_2\" value=\"Not anxious at all (1)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_2\" value=\"Slightly anxious (2)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_2\" value=\"Fairly anxious (3)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_2\" value=\"Very anxious (4)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_2\" value=\"Extremely anxious (5)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >If you were about to have a dental cleaning, how would you feel?<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_3\" value=\"Not anxious at all (1)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_3\" value=\"Slightly anxious (2)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_3\" value=\"Fairly anxious (3)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_3\" value=\"Very anxious (4)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_3\" value=\"Extremely anxious (5)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >If you were about to receive a local anesthetic injection to numb a tooth, how would you feel?<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_4\" value=\"Not anxious at all (1)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_4\" value=\"Slightly anxious (2)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_4\" value=\"Fairly anxious (3)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_4\" value=\"Very anxious (4)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field81_4\" value=\"Extremely anxious (5)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><\/tbody><\/table><\/div><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field82\" data-index=\"64\" style=\"width: 100%\" class=\" form-element form-element-field82 options-false default-true form-element-type-checkbox is-required-false odd form-element-64 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-false checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >What is your score from the previous question?<\/span><\/span><span class=\"sub-label\"><span >Add up the points from each of your answers to the previous question to get your total score.<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field82\" type=\"radio\" data-is-required=\"false\" name=\"field82[]\" value=\"No fear (5)\" class=\"validation-lenient\"><span><span >No fear (5)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field82\" type=\"radio\" data-is-required=\"false\" name=\"field82[]\" value=\"Low fear (6-8)\" class=\"validation-lenient\"><span><span >Low fear (6-8)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field82\" type=\"radio\" data-is-required=\"false\" name=\"field82[]\" value=\"Moderate fear (9-14)\" class=\"validation-lenient\"><span><span >Moderate fear (9-14)<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field82\" type=\"radio\" data-is-required=\"false\" name=\"field82[]\" value=\"High fear (15-20)\" class=\"validation-lenient\"><span><span >High fear (15-20)<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field77\" data-index=\"65\" style=\"width: 100%\" class=\" form-element form-element-field77 options-false default-false form-element-type-oneLineText is-required-false even form-element-65 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Patient signature<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Patient signature\" make-read-only=\"false\" data-field-id=\"field77\" name=\"field77[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field78\" data-index=\"66\" style=\"width: 100%\" class=\" form-element form-element-field78 options-false default-false form-element-type-datepicker is-required-false odd form-element-66 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Date<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field78\" placeholder=\"Date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"false\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"yy-mm-dd\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"en\" name=\"field78\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field79\" data-index=\"67\" style=\"width: 100%\" class=\" form-element form-element-field79 options-false default-false form-element-type-submit is-required-false even form-element-67 -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-left wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><label ><input type=\"text\" class=\"required_field\" name=\"website\" autocomplete=\"maple-syrup-pot\"><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 99%px; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><\/div>\n<\/div><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-2 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:32px\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n","protected":false},"excerpt":{"rendered":"MEDICAL FORM 1 Step 1 Name of patient File numberfolder First name of patient Sex Telephonephone Emaila valid emailemail Adress Town Postal Code Birth datedate_range Occupation Assurance maladie card numberpayment Expiration datedate_range Family physician name Dentist name Weight Name, adress and telephone number pharmacy Please answer all questions Have you ever taken the following medications...","protected":false},"author":3,"featured_media":0,"parent":943,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-321","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Medical form | Maxillo-Mauricie<\/title>\n<meta name=\"description\" content=\"Please complete your online medical form before the day of your initial consultation.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/maxillomauricie.com\/en\/new-patients\/medical-form\/\" \/>\n<meta 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