{"id":2174,"date":"2023-09-29T16:50:55","date_gmt":"2023-09-29T16:50:55","guid":{"rendered":"https:\/\/websitedemolynks.co\/markianbabij\/?page_id=2174"},"modified":"2023-09-29T17:35:29","modified_gmt":"2023-09-29T17:35:29","slug":"new-patient-for","status":"publish","type":"page","link":"http:\/\/websitedemolynks.co\/markianbabij\/new-patient-for\/","title":{"rendered":"New Patient For"},"content":{"rendered":"<p>[vc_section][vc_row][vc_column]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_2' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/markianbabij\/wp-json\/wp\/v2\/pages\/2174' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_2_3\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><h2 class=\"gat-heading\">The Ellenburg Center For Natural Medicine, Inc.<br>\nAnchorage, Alaska 99508<\/h2>\n\n<div class=\"num-form\">\n<a href=\"tel:907-563-2366\"><span>Phone:<\/span> 907-563-2366<\/a>\n\n<a href=\"tel:907-563-2365\"><span>Fax:<\/span> 907-563-2365<\/a>\n<\/div>\n\n<div class=\"pat-info\">\n<h3>Patient Information Sheet<br>\n(Please Print Clearly)<\/h3>\n<\/div><\/div><div id=\"field_2_7\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label' for='input_2_7' >Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_2_7' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_7' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_8\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\"><legend class='gfield_label gfield_label_before_complex'  >Name:<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_2_8'>\n                            \n                            <span id='input_2_8_3_container' class='name_first' >\n                                                    <input type='text' name='input_8.3' id='input_2_8_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_8_3' >First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_2_9\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\"><label class='gfield_label' for='input_2_9' >Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_2_9' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\"><label class='gfield_label' for='input_2_10' >Email Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_2_10' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_2_27\"  class=\"gfield gfield--width-full field_sublabel_above field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><legend class='gfield_label gfield_label_before_complex'  >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_city has_state has_zip ginput_container_address' id='input_2_27' >\n                        <span class='ginput_left address_city ginput_address_city' id='input_2_27_3_container' >\n                                    <label for='input_2_27_3' id='input_2_27_3_label' >City:<\/label>\n                                    <input type='text' name='input_27.3' id='input_2_27_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_27_4_container' >\n                                        <label for='input_2_27_4' id='input_2_27_4_label' >State:<\/label>\n                                        <input type='text' name='input_27.4' id='input_2_27_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_27_5_container' >\n                                    <label for='input_2_27_5' id='input_2_27_5_label' >Zip:<\/label>\n                                    <input type='text' name='input_27.5' id='input_2_27_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_27.6' id='input_2_27_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_18\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\"><label class='gfield_label' for='input_2_18' >Date of Birth:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_2_18' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_18_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_18' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_20\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label' for='input_2_20' >Age:<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_19\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\"><label class='gfield_label' for='input_2_19' >SS#<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_21\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><legend class='gfield_label gfield_label_before_complex'  >Sex:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_21'><div class='gchoice gchoice_2_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Male'  id='choice_2_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1'>Male<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Female'  id='choice_2_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_2' id='label_2_21_2'>Female<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_22\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label' for='input_2_22' >Marital Status:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_23\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><label class='gfield_label' for='input_2_23' >Spouse\/Partner Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_25\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label' for='input_2_25' >Employer:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_24\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\"><label class='gfield_label' for='input_2_24' >Phone:<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_26\"  class=\"gfield field_sublabel_above field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><legend class='gfield_label screen-reader-text gfield_label_before_complex'  ><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address' id='input_2_26' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_2_26_1_container' >\n                                        <label for='input_2_26_1' id='input_2_26_1_label' >Employer Address:<\/label>\n                                        <input type='text' name='input_26.1' id='input_2_26_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city' id='input_2_26_3_container' >\n                                    <label for='input_2_26_3' id='input_2_26_3_label' >City:<\/label>\n                                    <input type='text' name='input_26.3' id='input_2_26_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_2_26_4_container' >\n                                        <label for='input_2_26_4' id='input_2_26_4_label' >State:<\/label>\n                                        <input type='text' name='input_26.4' id='input_2_26_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_2_26_5_container' >\n                                    <label for='input_2_26_5' id='input_2_26_5_label' >Zip:<\/label>\n                                    <input type='text' name='input_26.5' id='input_2_26_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_26.6' id='input_2_26_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_28\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label' for='input_2_28' >Emergency Contact:<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_2_28' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_29\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label' for='input_2_29' >Phone:<\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_2_29' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 3;\"><\/div><div id=\"field_2_30\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><label class='gfield_label' for='input_2_30' >Allergies:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_2_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_86\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_86\"><label class='gfield_label' for='input_2_86' >Reason For Visit:<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_2_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 3;\"><\/div><div id=\"field_2_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label' for='input_2_32' >How did you hear about us?<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_33\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\"><label class='gfield_label' for='input_2_33' >Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_2_33' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_34\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><h3 class=\"get-list\">I understand the following:<br>\nThis clinic is not a Medicare\/Medicaid Provider<br>\nDr. Michael Ellenburg does not accept insurance. Full payment is due at time of service.<\/h3><\/div><div id=\"field_2_36\"  class=\"gfield gfield--width-seven-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label' for='input_2_36' >Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_38\"  class=\"gfield gfield--width-five-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_38\"><label class='gfield_label' for='input_2_38' >Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_2_38' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_38_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_38_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_38' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_39\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><label class='gfield_label' for='input_2_39' >Today&#039;s Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_39' id='input_2_39' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_39_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_39_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_39' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_40\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_40\">Please score each symptom, based on today's date, using a scale of 0-10 (0=none and l0=severe). This flow sheet can be used to follow the progression or regression of a patient's treatment<\/div><div id=\"field_2_78\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_78\"><h4 class=\"four-heading\">SYMPTOM<\/h4><\/div><div id=\"field_2_46\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label' for='input_2_46' >Unexplained irritability<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_47\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><label class='gfield_label' for='input_2_47' >Constant or very frequent periods of depression<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_2_47' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 5;\"><\/div><div id=\"field_2_55\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><label class='gfield_label' for='input_2_55' >Numbness and tingling in extremities<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_56\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\"><label class='gfield_label' for='input_2_56' >Frequent urination during the night<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_54\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_54\"><label class='gfield_label' for='input_2_54' >Cold hands and feet, even in moderate weather<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_2_54' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_57\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><label class='gfield_label' for='input_2_57' >Unexplained chronic fatigue<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_50\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><label class='gfield_label' for='input_2_50' >Bloated feeling<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_53\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><label class='gfield_label' for='input_2_53' >Poor memory or Brain fog<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_2_53' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_52\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><label class='gfield_label' for='input_2_52' >Sudden, unexplained anger<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_49\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><label class='gfield_label' for='input_2_49' >Constipation<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_2_49' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_51\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><label class='gfield_label' for='input_2_51' >Difficulty making decisions<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_48\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><label class='gfield_label' for='input_2_48' >Tremors or shakes of hands, feet, head, etc.<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_58\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\"><label class='gfield_label' for='input_2_58' >Muscle twitches<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_64\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><label class='gfield_label' for='input_2_64' >Frequent leg cramps<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_2_64' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_63\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><label class='gfield_label' for='input_2_63' >Ringing in ears<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_2_63' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_65\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><label class='gfield_label' for='input_2_65' >Get out of breath easily<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_2_65' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_62\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><label class='gfield_label' for='input_2_62' >Heartburn<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_2_62' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_61\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><label class='gfield_label' for='input_2_61' >Excessive itching<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_2_61' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_60\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><label class='gfield_label' for='input_2_60' >Unexplained rashes, skin irritation<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_59\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_59\"><label class='gfield_label' for='input_2_59' >Metallic taste in mouth<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_66\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_66\"><label class='gfield_label' for='input_2_66' >Jumpy, jittery, nervous<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_2_66' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_72\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_72\"><label class='gfield_label' for='input_2_72' >Suicidal thoughts<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_2_72' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_71\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_71\"><label class='gfield_label' for='input_2_71' >Insomnia<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_2_71' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_70\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_70\"><label class='gfield_label' for='input_2_70' >Unexplained chest pains<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_2_70' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_69\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_69\"><label class='gfield_label' for='input_2_69' >Constant or frequent pain in joints<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_2_69' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_68\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_68\"><label class='gfield_label' for='input_2_68' >Rapid heart rate<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_67\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_67\"><label class='gfield_label' for='input_2_67' >Unexplained fluid retention<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_73\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_73\"><label class='gfield_label' for='input_2_73' >Burning sensation on the tongue<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_74\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_74\"><label class='gfield_label' for='input_2_74' >Headaches after eating<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_2_74' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_76\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_76\"><label class='gfield_label' for='input_2_76' >Frequent diarrhea<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_2_76' type='text' value='' class='large'    placeholder='Rating'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_79\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_79\"><h2 class=\"gat-heading\">Dr. Ellenburg Center For Natural Medicine, Inc.<br>\n3500 Latouche St. Suite 360<br>\nAnchorage, Alaska 99508<\/h2>\n\n<div class=\"num-form\">\n<a href=\"tel:907-563-2366\"><span>Phone:<\/span> 907-563-2366<\/a>\n\n<a href=\"tel:907-563-2365\"><span>Fax:<\/span> 907-563-2365<\/a>\n<\/div>\n\n<div class=\"pat-info\">\n<h3>Patient Information Sheet<br>\n(Please Print Clearly)<\/h3>\n<\/div><\/div><div id=\"field_2_80\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_80\"><label class='gfield_label' for='input_2_80' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_2_80' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_80_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_80_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_80' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_82\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_82\"><legend class='gfield_label gfield_label_before_complex'  >Name<\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_2_82'>\n                            \n                            <span id='input_2_82_3_container' class='name_first' >\n                                                    <input type='text' name='input_82.3' id='input_2_82_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_82_3' >Name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_2_83\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_83\"><label class='gfield_label' for='input_2_83' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_83' id='input_2_83' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_83_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_83_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_83' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_84\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_84\"><label class='gfield_label' for='input_2_84' >Major Complaints<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_2_84' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_85\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_85\"><label class='gfield_label' for='input_2_85' >Date ofLast Physical and\/or Physician Visit<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_2_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 3;\"><\/div><div id=\"field_2_87\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_87\"><h3>Check boxes below and circle symptoms when necessary<\/h3>\n\n\n<h4>General Symptoms<\/h4><\/div><fieldset id=\"field_2_88\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_88\"><legend class='gfield_label gfield_label_before_complex'  >Tired, weak, lack ofenergy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_88'><div class='gchoice gchoice_2_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Present'  id='choice_2_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_88_1' id='label_2_88_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Past'  id='choice_2_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_88_2' id='label_2_88_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_89\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_89\"><legend class='gfield_label gfield_label_before_complex'  >Weight Gain or Loss<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_89'><div class='gchoice gchoice_2_89_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.1' type='checkbox'  value='Present'  id='choice_2_89_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_89_1' id='label_2_89_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_89_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_89.2' type='checkbox'  value='Past'  id='choice_2_89_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_89_2' id='label_2_89_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_90\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_90\"><legend class='gfield_label gfield_label_before_complex'  >Frequent colds or other illnesses<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_90'><div class='gchoice gchoice_2_90_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.1' type='checkbox'  value='Present'  id='choice_2_90_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_90_1' id='label_2_90_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_90_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_90.2' type='checkbox'  value='Past'  id='choice_2_90_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_90_2' id='label_2_90_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_91\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_91\"><legend class='gfield_label gfield_label_before_complex'  >Headaches or migraines<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_91'><div class='gchoice gchoice_2_91_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.1' type='checkbox'  value='Present'  id='choice_2_91_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_91_1' id='label_2_91_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_91_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.2' type='checkbox'  value='Past'  id='choice_2_91_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_91_2' id='label_2_91_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_93\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_93\"><legend class='gfield_label gfield_label_before_complex'  >Dizziness, fainting<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_93'><div class='gchoice gchoice_2_93_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.1' type='checkbox'  value='Present'  id='choice_2_93_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_93_1' id='label_2_93_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_93_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.2' type='checkbox'  value='Past'  id='choice_2_93_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_93_2' id='label_2_93_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><fieldset id=\"field_2_92\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_92\"><legend class='gfield_label gfield_label_before_complex'  >Fever, chills<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_92'><div class='gchoice gchoice_2_92_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.1' type='checkbox'  value='Present'  id='choice_2_92_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_92_1' id='label_2_92_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_92_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_92.2' type='checkbox'  value='Past'  id='choice_2_92_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_92_2' id='label_2_92_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_94\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_94\"><h4>Blurry Vision<\/h4><\/div><fieldset id=\"field_2_95\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_95\"><legend class='gfield_label gfield_label_before_complex'  >Nearsighted or Farsighted<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_95'><div class='gchoice gchoice_2_95_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.1' type='checkbox'  value='Present'  id='choice_2_95_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_95_1' id='label_2_95_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_95_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_95.2' type='checkbox'  value='Past'  id='choice_2_95_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_95_2' id='label_2_95_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_99\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_99\"><legend class='gfield_label gfield_label_before_complex'  >Blurry Vision<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_99'><div class='gchoice gchoice_2_99_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.1' type='checkbox'  value='Present'  id='choice_2_99_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_99_1' id='label_2_99_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_99_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.2' type='checkbox'  value='Past'  id='choice_2_99_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_99_2' id='label_2_99_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_98\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_98\"><legend class='gfield_label gfield_label_before_complex'  >Blurry Vision<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_98'><div class='gchoice gchoice_2_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Present'  id='choice_2_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_98_1' id='label_2_98_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Past'  id='choice_2_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_98_2' id='label_2_98_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_100\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_100\"><h4>Eyes<\/h4><\/div><fieldset id=\"field_2_96\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_96\"><legend class='gfield_label gfield_label_before_complex'  >Acne or pimples<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_96'><div class='gchoice gchoice_2_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='Present'  id='choice_2_96_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_96_1' id='label_2_96_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_96_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.2' type='checkbox'  value='Past'  id='choice_2_96_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_96_2' id='label_2_96_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_103\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_103\"><legend class='gfield_label gfield_label_before_complex'  >Acne or pimples<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_103'><div class='gchoice gchoice_2_103_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.1' type='checkbox'  value='Present'  id='choice_2_103_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_103_1' id='label_2_103_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_103_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.2' type='checkbox'  value='Past'  id='choice_2_103_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_103_2' id='label_2_103_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_102\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_102\"><legend class='gfield_label gfield_label_before_complex'  >Itching<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_102'><div class='gchoice gchoice_2_102_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.1' type='checkbox'  value='Present'  id='choice_2_102_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_102_1' id='label_2_102_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_102_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_102.2' type='checkbox'  value='Past'  id='choice_2_102_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_102_2' id='label_2_102_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><fieldset id=\"field_2_101\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_101\"><legend class='gfield_label gfield_label_before_complex'  >Dry Skin<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_101'><div class='gchoice gchoice_2_101_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.1' type='checkbox'  value='Present'  id='choice_2_101_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_101_1' id='label_2_101_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_101_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.2' type='checkbox'  value='Past'  id='choice_2_101_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_101_2' id='label_2_101_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_97\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_97\"><legend class='gfield_label gfield_label_before_complex'  >Hair loss<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_97'><div class='gchoice gchoice_2_97_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.1' type='checkbox'  value='Present'  id='choice_2_97_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_97_1' id='label_2_97_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_97_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_97.2' type='checkbox'  value='Past'  id='choice_2_97_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_97_2' id='label_2_97_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_104\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_104\"><legend class='gfield_label gfield_label_before_complex'  >Hair dry and brittle<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_104'><div class='gchoice gchoice_2_104_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.1' type='checkbox'  value='Present'  id='choice_2_104_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_104_1' id='label_2_104_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_104_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_104.2' type='checkbox'  value='Past'  id='choice_2_104_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_104_2' id='label_2_104_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_105\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_105\"><h4>Ears<\/h4><\/div><fieldset id=\"field_2_106\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_106\"><legend class='gfield_label gfield_label_before_complex'  >Ringing in the ears<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_106'><div class='gchoice gchoice_2_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Present'  id='choice_2_106_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_106_1' id='label_2_106_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='Past'  id='choice_2_106_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_106_2' id='label_2_106_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_108\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_108\"><legend class='gfield_label gfield_label_before_complex'  >Loss of hearing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_108'><div class='gchoice gchoice_2_108_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.1' type='checkbox'  value='Present'  id='choice_2_108_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_108_1' id='label_2_108_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_108_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.2' type='checkbox'  value='Past'  id='choice_2_108_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_108_2' id='label_2_108_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_107\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_107\"><legend class='gfield_label gfield_label_before_complex'  >Excessive ear wax<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_107'><div class='gchoice gchoice_2_107_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.1' type='checkbox'  value='Present'  id='choice_2_107_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_107_1' id='label_2_107_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_107_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.2' type='checkbox'  value='Past'  id='choice_2_107_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_107_2' id='label_2_107_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_109\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_109\"><h4>Respiratory<\/h4><\/div><fieldset id=\"field_2_110\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_110\"><legend class='gfield_label gfield_label_before_complex'  >Cough Frequently, Allergies<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_110'><div class='gchoice gchoice_2_110_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.1' type='checkbox'  value='Present'  id='choice_2_110_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_110_1' id='label_2_110_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_110_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_110.2' type='checkbox'  value='Past'  id='choice_2_110_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_110_2' id='label_2_110_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_113\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_113\"><legend class='gfield_label gfield_label_before_complex'  >Wheezing, Shortness ofBreath<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_113'><div class='gchoice gchoice_2_113_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.1' type='checkbox'  value='Present'  id='choice_2_113_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_113_1' id='label_2_113_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_113_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.2' type='checkbox'  value='Past'  id='choice_2_113_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_113_2' id='label_2_113_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_112\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_112\"><legend class='gfield_label gfield_label_before_complex'  >Pneumonia, bronchitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_112'><div class='gchoice gchoice_2_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='Present'  id='choice_2_112_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_112_1' id='label_2_112_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='Past'  id='choice_2_112_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_112_2' id='label_2_112_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_111\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_111\"><legend class='gfield_label gfield_label_before_complex'  >Coughing up mucous or blood<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_111'><div class='gchoice gchoice_2_111_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_111.1' type='checkbox'  value='Present'  id='choice_2_111_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_111_1' id='label_2_111_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_111_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_111.2' type='checkbox'  value='Past'  id='choice_2_111_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_111_2' id='label_2_111_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 8;\"><\/div><div id=\"field_2_114\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_114\"><h4>Sleep<\/h4><\/div><fieldset id=\"field_2_115\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_115\"><legend class='gfield_label gfield_label_before_complex'  >Sinusitis acute or chronic<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_115'><div class='gchoice gchoice_2_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='Present'  id='choice_2_115_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_115_1' id='label_2_115_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='Past'  id='choice_2_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_115_2' id='label_2_115_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_119\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_119\"><legend class='gfield_label gfield_label_before_complex'  >Sore throat or Runny Nose<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_119'><div class='gchoice gchoice_2_119_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.1' type='checkbox'  value='Present'  id='choice_2_119_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_119_1' id='label_2_119_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_119_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_119.2' type='checkbox'  value='Past'  id='choice_2_119_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_119_2' id='label_2_119_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_118\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_118\"><legend class='gfield_label gfield_label_before_complex'  >Cold sores or herpes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_118'><div class='gchoice gchoice_2_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='Present'  id='choice_2_118_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_118_1' id='label_2_118_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='Past'  id='choice_2_118_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_118_2' id='label_2_118_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_117\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_117\"><legend class='gfield_label gfield_label_before_complex'  >Decreased smell or taste<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_117'><div class='gchoice gchoice_2_117_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.1' type='checkbox'  value='Present'  id='choice_2_117_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_117_1' id='label_2_117_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_117_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.2' type='checkbox'  value='Past'  id='choice_2_117_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_117_2' id='label_2_117_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><fieldset id=\"field_2_116\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_116\"><legend class='gfield_label gfield_label_before_complex'  >Cavities, tooth pain<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_116'><div class='gchoice gchoice_2_116_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.1' type='checkbox'  value='Present'  id='choice_2_116_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_116_1' id='label_2_116_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_116_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.2' type='checkbox'  value='Past'  id='choice_2_116_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_116_2' id='label_2_116_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_121\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_121\"><legend class='gfield_label gfield_label_before_complex'  >Bleeding gums, infections<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_121'><div class='gchoice gchoice_2_121_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Present'  id='choice_2_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_121_1' id='label_2_121_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_121_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Past'  id='choice_2_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_121_2' id='label_2_121_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_122\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_122\"><legend class='gfield_label gfield_label_before_complex'  >Chronic Congestion,<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_122'><div class='gchoice gchoice_2_122_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.1' type='checkbox'  value='Present'  id='choice_2_122_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_122_1' id='label_2_122_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_122_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.2' type='checkbox'  value='Past'  id='choice_2_122_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_122_2' id='label_2_122_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_120\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_120\"><legend class='gfield_label gfield_label_before_complex'  >Thyroid Disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_120'><div class='gchoice gchoice_2_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='Present'  id='choice_2_120_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_120_1' id='label_2_120_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='Past'  id='choice_2_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_120_2' id='label_2_120_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_123\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_123\"><h4>Sleep<\/h4><\/div><fieldset id=\"field_2_124\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_124\"><legend class='gfield_label gfield_label_before_complex'  >Sleep too much or Sleep too little<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_124'><div class='gchoice gchoice_2_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Present'  id='choice_2_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_124_1' id='label_2_124_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='Past'  id='choice_2_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_124_2' id='label_2_124_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_127\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_127\"><legend class='gfield_label gfield_label_before_complex'  >Trouble falling asleep or Staying Asleep<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_127'><div class='gchoice gchoice_2_127_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.1' type='checkbox'  value='Present'  id='choice_2_127_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_127_1' id='label_2_127_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_127_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_127.2' type='checkbox'  value='Past'  id='choice_2_127_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_127_2' id='label_2_127_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_129\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_129\"><legend class='gfield_label gfield_label_before_complex'  >Restlessness or Restless legs<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_129'><div class='gchoice gchoice_2_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='Present'  id='choice_2_129_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_129_1' id='label_2_129_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_129_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.2' type='checkbox'  value='Past'  id='choice_2_129_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_129_2' id='label_2_129_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_126\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_126\"><legend class='gfield_label gfield_label_before_complex'  >Snoring or Sleep apnea<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_126'><div class='gchoice gchoice_2_126_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.1' type='checkbox'  value='Present'  id='choice_2_126_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_126_1' id='label_2_126_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_126_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.2' type='checkbox'  value='Past'  id='choice_2_126_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_126_2' id='label_2_126_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_130\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_130\"><h4>Musculoskeletal<\/h4><\/div><fieldset id=\"field_2_125\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_125\"><legend class='gfield_label gfield_label_before_complex'  >Muscle pain\/stiffness, where<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_125'><div class='gchoice gchoice_2_125_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.1' type='checkbox'  value='Present'  id='choice_2_125_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_125_1' id='label_2_125_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_125_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_125.2' type='checkbox'  value='Past'  id='choice_2_125_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_125_2' id='label_2_125_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_128\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_128\"><legend class='gfield_label gfield_label_before_complex'  >Fracture<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_128'><div class='gchoice gchoice_2_128_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.1' type='checkbox'  value='Present'  id='choice_2_128_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_128_1' id='label_2_128_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_128_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_128.2' type='checkbox'  value='Past'  id='choice_2_128_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_128_2' id='label_2_128_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_131\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_131\"><legend class='gfield_label gfield_label_before_complex'  >Bone pain, where?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_131'><div class='gchoice gchoice_2_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='Present'  id='choice_2_131_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_131_1' id='label_2_131_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_131_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.2' type='checkbox'  value='Past'  id='choice_2_131_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_131_2' id='label_2_131_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_132\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_132\"><legend class='gfield_label gfield_label_before_complex'  >Painful or stiff joints<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_132'><div class='gchoice gchoice_2_132_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.1' type='checkbox'  value='Present'  id='choice_2_132_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_132_1' id='label_2_132_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_132_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_132.2' type='checkbox'  value='Past'  id='choice_2_132_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_132_2' id='label_2_132_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_133\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_133\"><h4>Musculoskeletal<\/h4><\/div><fieldset id=\"field_2_134\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_134\"><legend class='gfield_label gfield_label_before_complex'  >Tingling, Numbness<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_134'><div class='gchoice gchoice_2_134_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.1' type='checkbox'  value='Present'  id='choice_2_134_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_134_1' id='label_2_134_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_134_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_134.2' type='checkbox'  value='Past'  id='choice_2_134_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_134_2' id='label_2_134_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_138\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_138\"><legend class='gfield_label gfield_label_before_complex'  >Heel Pain, Foot Pain<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_138'><div class='gchoice gchoice_2_138_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.1' type='checkbox'  value='Present'  id='choice_2_138_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_138_1' id='label_2_138_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_138_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.2' type='checkbox'  value='Past'  id='choice_2_138_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_138_2' id='label_2_138_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_137\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_137\"><legend class='gfield_label gfield_label_before_complex'  >Weakness<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_137'><div class='gchoice gchoice_2_137_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.1' type='checkbox'  value='Present'  id='choice_2_137_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_137_1' id='label_2_137_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_137_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_137.2' type='checkbox'  value='Past'  id='choice_2_137_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_137_2' id='label_2_137_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_136\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_136\"><legend class='gfield_label gfield_label_before_complex'  >Tremors, Cramps<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_136'><div class='gchoice gchoice_2_136_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.1' type='checkbox'  value='Present'  id='choice_2_136_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_136_1' id='label_2_136_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_136_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_136.2' type='checkbox'  value='Past'  id='choice_2_136_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_136_2' id='label_2_136_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><div id=\"field_2_139\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_139\"><h4>Cardiovascular<\/h4><\/div><fieldset id=\"field_2_135\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_135\"><legend class='gfield_label gfield_label_before_complex'  >Heart beats fast or irregular<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_135'><div class='gchoice gchoice_2_135_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.1' type='checkbox'  value='Present'  id='choice_2_135_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_135_1' id='label_2_135_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_135_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.2' type='checkbox'  value='Past'  id='choice_2_135_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_135_2' id='label_2_135_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_142\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_142\"><legend class='gfield_label gfield_label_before_complex'  >Tightness or pain in chest<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_142'><div class='gchoice gchoice_2_142_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.1' type='checkbox'  value='Present'  id='choice_2_142_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_142_1' id='label_2_142_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_142_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_142.2' type='checkbox'  value='Past'  id='choice_2_142_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_142_2' id='label_2_142_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_141\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_141\"><legend class='gfield_label gfield_label_before_complex'  >Dizziness upon standing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_141'><div class='gchoice gchoice_2_141_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_141.1' type='checkbox'  value='Present'  id='choice_2_141_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_141_1' id='label_2_141_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_141_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_141.2' type='checkbox'  value='Past'  id='choice_2_141_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_141_2' id='label_2_141_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_140\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_140\"><legend class='gfield_label gfield_label_before_complex'  >Swollen Feet or Ankles<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_140'><div class='gchoice gchoice_2_140_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.1' type='checkbox'  value='Present'  id='choice_2_140_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_140_1' id='label_2_140_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_140_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.2' type='checkbox'  value='Past'  id='choice_2_140_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_140_2' id='label_2_140_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 9;\"><\/div><fieldset id=\"field_2_144\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_144\"><legend class='gfield_label gfield_label_before_complex'  >Cold Hands and Feet<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_144'><div class='gchoice gchoice_2_144_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.1' type='checkbox'  value='Present'  id='choice_2_144_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_144_1' id='label_2_144_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_144_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.2' type='checkbox'  value='Past'  id='choice_2_144_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_144_2' id='label_2_144_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_147\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_147\"><legend class='gfield_label gfield_label_before_complex'  >Leg pain when walking<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_147'><div class='gchoice gchoice_2_147_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.1' type='checkbox'  value='Present'  id='choice_2_147_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_147_1' id='label_2_147_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_147_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.2' type='checkbox'  value='Past'  id='choice_2_147_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_147_2' id='label_2_147_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_146\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_146\"><legend class='gfield_label gfield_label_before_complex'  >Varicose Veins<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_146'><div class='gchoice gchoice_2_146_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.1' type='checkbox'  value='Present'  id='choice_2_146_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_146_1' id='label_2_146_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_146_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_146.2' type='checkbox'  value='Past'  id='choice_2_146_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_146_2' id='label_2_146_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_145\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_145\"><legend class='gfield_label gfield_label_before_complex'  >Heart Murmur<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_145'><div class='gchoice gchoice_2_145_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.1' type='checkbox'  value='Present'  id='choice_2_145_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_145_1' id='label_2_145_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_145_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.2' type='checkbox'  value='Past'  id='choice_2_145_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_145_2' id='label_2_145_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_148\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_148\"><legend class='gfield_label gfield_label_before_complex'  >High Blood Pressure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_148'><div class='gchoice gchoice_2_148_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.1' type='checkbox'  value='Present'  id='choice_2_148_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_148_1' id='label_2_148_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_148_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_148.2' type='checkbox'  value='Past'  id='choice_2_148_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_148_2' id='label_2_148_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_151\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_151\"><legend class='gfield_label gfield_label_before_complex'  >Low Blood Pressure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_151'><div class='gchoice gchoice_2_151_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.1' type='checkbox'  value='Present'  id='choice_2_151_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_151_1' id='label_2_151_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_151_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.2' type='checkbox'  value='Past'  id='choice_2_151_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_151_2' id='label_2_151_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_150\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_150\"><legend class='gfield_label gfield_label_before_complex'  >Heart attacks or Strokes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_150'><div class='gchoice gchoice_2_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='Present'  id='choice_2_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_150_1' id='label_2_150_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='Past'  id='choice_2_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_150_2' id='label_2_150_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_149\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_149\"><legend class='gfield_label gfield_label_before_complex'  >Aneurysms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_149'><div class='gchoice gchoice_2_149_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.1' type='checkbox'  value='Present'  id='choice_2_149_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_149_1' id='label_2_149_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_149_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_149.2' type='checkbox'  value='Past'  id='choice_2_149_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_149_2' id='label_2_149_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_152\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_152\"><h4>Gast rointestinal<\/h4><\/div><fieldset id=\"field_2_153\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_153\"><legend class='gfield_label gfield_label_before_complex'  >Increased Appetite<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_153'><div class='gchoice gchoice_2_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Present'  id='choice_2_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_153_1' id='label_2_153_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_153_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.2' type='checkbox'  value='Past'  id='choice_2_153_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_153_2' id='label_2_153_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_161\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_161\"><legend class='gfield_label gfield_label_before_complex'  >Loss of Appetite<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_161'><div class='gchoice gchoice_2_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Present'  id='choice_2_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_1' id='label_2_161_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_161_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.2' type='checkbox'  value='Past'  id='choice_2_161_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_161_2' id='label_2_161_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_160\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_160\"><legend class='gfield_label gfield_label_before_complex'  >Nausea or Vomiting<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_160'><div class='gchoice gchoice_2_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Present'  id='choice_2_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_1' id='label_2_160_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='Past'  id='choice_2_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_160_2' id='label_2_160_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_159\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_159\"><legend class='gfield_label gfield_label_before_complex'  >Bad breath, metallic taste<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_159'><div class='gchoice gchoice_2_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Present'  id='choice_2_159_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_1' id='label_2_159_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_159_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.2' type='checkbox'  value='Past'  id='choice_2_159_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_159_2' id='label_2_159_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_156\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_156\"><legend class='gfield_label gfield_label_before_complex'  >Heartburn or Indigestion<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_156'><div class='gchoice gchoice_2_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Present'  id='choice_2_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_156_1' id='label_2_156_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_156_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.2' type='checkbox'  value='Past'  id='choice_2_156_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_156_2' id='label_2_156_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_155\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_155\"><legend class='gfield_label gfield_label_before_complex'  >Heaviness after eating<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_155'><div class='gchoice gchoice_2_155_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.1' type='checkbox'  value='Present'  id='choice_2_155_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_155_1' id='label_2_155_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_155_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.2' type='checkbox'  value='Past'  id='choice_2_155_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_155_2' id='label_2_155_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_158\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_158\"><legend class='gfield_label gfield_label_before_complex'  >Frequent Gas or Burping<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_158'><div class='gchoice gchoice_2_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Present'  id='choice_2_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_158_1' id='label_2_158_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_158_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.2' type='checkbox'  value='Past'  id='choice_2_158_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_158_2' id='label_2_158_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_154\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_154\"><legend class='gfield_label gfield_label_before_complex'  >Stomach or Abdominal Pain<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_154'><div class='gchoice gchoice_2_154_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.1' type='checkbox'  value='Present'  id='choice_2_154_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_154_1' id='label_2_154_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_154_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.2' type='checkbox'  value='Past'  id='choice_2_154_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_154_2' id='label_2_154_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_157\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_157\"><legend class='gfield_label gfield_label_before_complex'  >Headaches, irritability if skip meals<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_157'><div class='gchoice gchoice_2_157_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_157.1' type='checkbox'  value='Present'  id='choice_2_157_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_157_1' id='label_2_157_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_157_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_157.2' type='checkbox'  value='Past'  id='choice_2_157_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_157_2' id='label_2_157_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_164\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_164\"><legend class='gfield_label gfield_label_before_complex'  >Diarrhea of Loose Stools<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_164'><div class='gchoice gchoice_2_164_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.1' type='checkbox'  value='Present'  id='choice_2_164_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_164_1' id='label_2_164_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_164_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.2' type='checkbox'  value='Past'  id='choice_2_164_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_164_2' id='label_2_164_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_163\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_163\"><legend class='gfield_label gfield_label_before_complex'  >Constipation<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_163'><div class='gchoice gchoice_2_163_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_163.1' type='checkbox'  value='Present'  id='choice_2_163_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_163_1' id='label_2_163_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_163_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_163.2' type='checkbox'  value='Past'  id='choice_2_163_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_163_2' id='label_2_163_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_162\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_162\"><legend class='gfield_label gfield_label_before_complex'  >Dark Stools<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_162'><div class='gchoice gchoice_2_162_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.1' type='checkbox'  value='Present'  id='choice_2_162_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_1' id='label_2_162_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_162_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.2' type='checkbox'  value='Past'  id='choice_2_162_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_162_2' id='label_2_162_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_168\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_168\"><legend class='gfield_label gfield_label_before_complex'  >Blood in stools<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_168'><div class='gchoice gchoice_2_168_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.1' type='checkbox'  value='Present'  id='choice_2_168_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_168_1' id='label_2_168_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_168_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.2' type='checkbox'  value='Past'  id='choice_2_168_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_168_2' id='label_2_168_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_167\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_167\"><legend class='gfield_label gfield_label_before_complex'  >Undigested food in stools<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_167'><div class='gchoice gchoice_2_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Present'  id='choice_2_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_1' id='label_2_167_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_167_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.2' type='checkbox'  value='Past'  id='choice_2_167_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_167_2' id='label_2_167_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_166\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_166\"><legend class='gfield_label gfield_label_before_complex'  >Hemorrhoids<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_166'><div class='gchoice gchoice_2_166_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.1' type='checkbox'  value='Present'  id='choice_2_166_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_166_1' id='label_2_166_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_166_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.2' type='checkbox'  value='Past'  id='choice_2_166_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_166_2' id='label_2_166_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_169\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_169\"><legend class='gfield_label gfield_label_before_complex'  >Anal Itching, Bleeding<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_169'><div class='gchoice gchoice_2_169_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.1' type='checkbox'  value='Present'  id='choice_2_169_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_169_1' id='label_2_169_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_169_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.2' type='checkbox'  value='Past'  id='choice_2_169_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_169_2' id='label_2_169_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_170\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_170\"><label class='gfield_label' for='input_2_170' >How often do you have a bowel movement?<\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_2_170' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_171\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_171\"><h4>Urinary<\/h4><\/div><fieldset id=\"field_2_172\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_172\"><legend class='gfield_label gfield_label_before_complex'  >Pain or burning with urination<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_172'><div class='gchoice gchoice_2_172_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.1' type='checkbox'  value='Present'  id='choice_2_172_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_172_1' id='label_2_172_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_172_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.2' type='checkbox'  value='Past'  id='choice_2_172_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_172_2' id='label_2_172_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_173\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_173\"><legend class='gfield_label gfield_label_before_complex'  >Urinating frequently at night<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_173'><div class='gchoice gchoice_2_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Present'  id='choice_2_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_173_1' id='label_2_173_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_173_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.2' type='checkbox'  value='Past'  id='choice_2_173_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_173_2' id='label_2_173_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_176\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_176\"><legend class='gfield_label gfield_label_before_complex'  >Incomplete urination or dribbling<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_176'><div class='gchoice gchoice_2_176_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_176.1' type='checkbox'  value='Present'  id='choice_2_176_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_176_1' id='label_2_176_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_176_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_176.2' type='checkbox'  value='Past'  id='choice_2_176_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_176_2' id='label_2_176_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_175\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_175\"><legend class='gfield_label gfield_label_before_complex'  >Narrowing of stream<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_175'><div class='gchoice gchoice_2_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='Present'  id='choice_2_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_175_1' id='label_2_175_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_175_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.2' type='checkbox'  value='Past'  id='choice_2_175_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_175_2' id='label_2_175_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_174\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_174\"><legend class='gfield_label gfield_label_before_complex'  >Hard to start stream<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_174'><div class='gchoice gchoice_2_174_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.1' type='checkbox'  value='Present'  id='choice_2_174_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_174_1' id='label_2_174_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_174_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.2' type='checkbox'  value='Past'  id='choice_2_174_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_174_2' id='label_2_174_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_178\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_178\"><legend class='gfield_label gfield_label_before_complex'  >Uncontrolled urination<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_178'><div class='gchoice gchoice_2_178_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.1' type='checkbox'  value='Present'  id='choice_2_178_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_1' id='label_2_178_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_178_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.2' type='checkbox'  value='Past'  id='choice_2_178_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_178_2' id='label_2_178_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_177\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_177\"><legend class='gfield_label gfield_label_before_complex'  >Bladder infections<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_177'><div class='gchoice gchoice_2_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='Present'  id='choice_2_177_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_177_1' id='label_2_177_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_177_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.2' type='checkbox'  value='Past'  id='choice_2_177_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_177_2' id='label_2_177_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_179\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_179\"><legend class='gfield_label gfield_label_before_complex'  >Kidneys Infection or Disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_179'><div class='gchoice gchoice_2_179_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.1' type='checkbox'  value='Present'  id='choice_2_179_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_179_1' id='label_2_179_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_179_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.2' type='checkbox'  value='Past'  id='choice_2_179_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_179_2' id='label_2_179_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_180\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_180\"><legend class='gfield_label gfield_label_before_complex'  >Kidney Stones<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_180'><div class='gchoice gchoice_2_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='Present'  id='choice_2_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_180_1' id='label_2_180_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_180_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.2' type='checkbox'  value='Past'  id='choice_2_180_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_180_2' id='label_2_180_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_181\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_181\"><h4>Neurological\/Psychological<\/h4><\/div><fieldset id=\"field_2_182\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_182\"><legend class='gfield_label gfield_label_before_complex'  >Farming<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_182'><div class='gchoice gchoice_2_182_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.1' type='checkbox'  value='Present'  id='choice_2_182_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_182_1' id='label_2_182_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_182_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.2' type='checkbox'  value='Past'  id='choice_2_182_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_182_2' id='label_2_182_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_187\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_187\"><legend class='gfield_label gfield_label_before_complex'  >Gardening<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_187'><div class='gchoice gchoice_2_187_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.1' type='checkbox'  value='Present'  id='choice_2_187_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_187_1' id='label_2_187_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_187_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_187.2' type='checkbox'  value='Past'  id='choice_2_187_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_187_2' id='label_2_187_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_186\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_186\"><legend class='gfield_label gfield_label_before_complex'  >Industrial Work<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_186'><div class='gchoice gchoice_2_186_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_186.1' type='checkbox'  value='Present'  id='choice_2_186_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_186_1' id='label_2_186_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_186_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_186.2' type='checkbox'  value='Past'  id='choice_2_186_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_186_2' id='label_2_186_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_185\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_185\"><legend class='gfield_label gfield_label_before_complex'  >Pesticides<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_185'><div class='gchoice gchoice_2_185_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.1' type='checkbox'  value='Present'  id='choice_2_185_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_185_1' id='label_2_185_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_185_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.2' type='checkbox'  value='Past'  id='choice_2_185_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_185_2' id='label_2_185_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_184\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_184\"><legend class='gfield_label gfield_label_before_complex'  >Petroleum Products<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_184'><div class='gchoice gchoice_2_184_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_184.1' type='checkbox'  value='Present'  id='choice_2_184_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_184_1' id='label_2_184_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_184_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_184.2' type='checkbox'  value='Past'  id='choice_2_184_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_184_2' id='label_2_184_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_183\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_183\"><legend class='gfield_label gfield_label_before_complex'  >Welding, Construction<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_183'><div class='gchoice gchoice_2_183_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.1' type='checkbox'  value='Present'  id='choice_2_183_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_183_1' id='label_2_183_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_183_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.2' type='checkbox'  value='Past'  id='choice_2_183_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_183_2' id='label_2_183_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_188\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_188\"><legend class='gfield_label gfield_label_before_complex'  >Laboratory, Mechanical Work<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_188'><div class='gchoice gchoice_2_188_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.1' type='checkbox'  value='Present'  id='choice_2_188_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_188_1' id='label_2_188_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_188_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.2' type='checkbox'  value='Past'  id='choice_2_188_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_188_2' id='label_2_188_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_189\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_189\"><h4>Exposure\/Work History<\/h4><\/div><fieldset id=\"field_2_190\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_190\"><legend class='gfield_label gfield_label_before_complex'  >Speech Problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_190'><div class='gchoice gchoice_2_190_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.1' type='checkbox'  value='Present'  id='choice_2_190_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_190_1' id='label_2_190_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_190_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_190.2' type='checkbox'  value='Past'  id='choice_2_190_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_190_2' id='label_2_190_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_194\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_194\"><legend class='gfield_label gfield_label_before_complex'  >Depression, Anxiety, Mood Swings<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_194'><div class='gchoice gchoice_2_194_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.1' type='checkbox'  value='Present'  id='choice_2_194_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_194_1' id='label_2_194_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_194_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_194.2' type='checkbox'  value='Past'  id='choice_2_194_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_194_2' id='label_2_194_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_193\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_193\"><legend class='gfield_label gfield_label_before_complex'  >Trouble Concentrating<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_193'><div class='gchoice gchoice_2_193_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.1' type='checkbox'  value='Present'  id='choice_2_193_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_193_1' id='label_2_193_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_193_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_193.2' type='checkbox'  value='Past'  id='choice_2_193_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_193_2' id='label_2_193_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_192\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_192\"><legend class='gfield_label gfield_label_before_complex'  >Memory Problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_192'><div class='gchoice gchoice_2_192_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_192.1' type='checkbox'  value='Present'  id='choice_2_192_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_192_1' id='label_2_192_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_192_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_192.2' type='checkbox'  value='Past'  id='choice_2_192_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_192_2' id='label_2_192_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_191\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_191\"><legend class='gfield_label gfield_label_before_complex'  >Lack of Interest in Activities or Work<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_191'><div class='gchoice gchoice_2_191_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.1' type='checkbox'  value='Present'  id='choice_2_191_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_191_1' id='label_2_191_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_191_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_191.2' type='checkbox'  value='Past'  id='choice_2_191_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_191_2' id='label_2_191_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_197\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_197\"><legend class='gfield_label gfield_label_before_complex'  >Weepy, Cry Easily<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_197'><div class='gchoice gchoice_2_197_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.1' type='checkbox'  value='Present'  id='choice_2_197_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_197_1' id='label_2_197_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_197_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.2' type='checkbox'  value='Past'  id='choice_2_197_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_197_2' id='label_2_197_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_196\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_196\"><legend class='gfield_label gfield_label_before_complex'  >Counseling or Psychiatric care<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_196'><div class='gchoice gchoice_2_196_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_196.1' type='checkbox'  value='Present'  id='choice_2_196_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_196_1' id='label_2_196_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_196_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_196.2' type='checkbox'  value='Past'  id='choice_2_196_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_196_2' id='label_2_196_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_195\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_195\"><legend class='gfield_label gfield_label_before_complex'  >Obsessive or Compulsive Behavior<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_195'><div class='gchoice gchoice_2_195_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.1' type='checkbox'  value='Present'  id='choice_2_195_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_195_1' id='label_2_195_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_195_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_195.2' type='checkbox'  value='Past'  id='choice_2_195_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_195_2' id='label_2_195_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_198\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_198\"><h4>Female History<\/h4><\/div><fieldset id=\"field_2_199\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_199\"><legend class='gfield_label gfield_label_before_complex'  >rregular Menstruation<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_199'><div class='gchoice gchoice_2_199_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.1' type='checkbox'  value='Present'  id='choice_2_199_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_199_1' id='label_2_199_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_199_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_199.2' type='checkbox'  value='Past'  id='choice_2_199_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_199_2' id='label_2_199_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_201\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_201\"><legend class='gfield_label gfield_label_before_complex'  >Premenstrual or Menstrual Pain<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_201'><div class='gchoice gchoice_2_201_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_201.1' type='checkbox'  value='Present'  id='choice_2_201_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_201_1' id='label_2_201_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_201_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_201.2' type='checkbox'  value='Past'  id='choice_2_201_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_201_2' id='label_2_201_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_200\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_200\"><legend class='gfield_label gfield_label_before_complex'  >Depression, Mood Swings with Menses<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_200'><div class='gchoice gchoice_2_200_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.1' type='checkbox'  value='Present'  id='choice_2_200_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_200_1' id='label_2_200_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_200_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_200.2' type='checkbox'  value='Past'  id='choice_2_200_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_200_2' id='label_2_200_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_202\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_202\"><legend class='gfield_label gfield_label_before_complex'  >Swollen or Painful Breasts<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_202'><div class='gchoice gchoice_2_202_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_202.1' type='checkbox'  value='Present'  id='choice_2_202_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_202_1' id='label_2_202_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_202_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_202.2' type='checkbox'  value='Past'  id='choice_2_202_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_202_2' id='label_2_202_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_203\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_203\"><legend class='gfield_label gfield_label_before_complex'  >Lumps or Discharge from Breasts<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_203'><div class='gchoice gchoice_2_203_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.1' type='checkbox'  value='Present'  id='choice_2_203_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_203_1' id='label_2_203_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_203_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.2' type='checkbox'  value='Past'  id='choice_2_203_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_203_2' id='label_2_203_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_205\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_205\"><legend class='gfield_label gfield_label_before_complex'  >Low Libido<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_205'><div class='gchoice gchoice_2_205_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_205.1' type='checkbox'  value='Present'  id='choice_2_205_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_205_1' id='label_2_205_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_205_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_205.2' type='checkbox'  value='Past'  id='choice_2_205_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_205_2' id='label_2_205_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_206\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_206\"><legend class='gfield_label gfield_label_before_complex'  >Pain with Intercourse<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_206'><div class='gchoice gchoice_2_206_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_206.1' type='checkbox'  value='Present'  id='choice_2_206_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_206_1' id='label_2_206_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_206_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_206.2' type='checkbox'  value='Past'  id='choice_2_206_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_206_2' id='label_2_206_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_204\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_204\"><legend class='gfield_label gfield_label_before_complex'  >Difficulty having an orgasm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_204'><div class='gchoice gchoice_2_204_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.1' type='checkbox'  value='Present'  id='choice_2_204_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_204_1' id='label_2_204_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_204_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.2' type='checkbox'  value='Past'  id='choice_2_204_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_204_2' id='label_2_204_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_207\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_207\"><legend class='gfield_label gfield_label_before_complex'  >Infertility<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_207'><div class='gchoice gchoice_2_207_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_207.1' type='checkbox'  value='Present'  id='choice_2_207_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_207_1' id='label_2_207_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_207_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_207.2' type='checkbox'  value='Past'  id='choice_2_207_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_207_2' id='label_2_207_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_210\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_210\"><legend class='gfield_label gfield_label_before_complex'  >Vaginal Discharge or Dryness<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_210'><div class='gchoice gchoice_2_210_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_210.1' type='checkbox'  value='Present'  id='choice_2_210_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_210_1' id='label_2_210_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_210_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_210.2' type='checkbox'  value='Past'  id='choice_2_210_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_210_2' id='label_2_210_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_209\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_209\"><legend class='gfield_label gfield_label_before_complex'  >Pain or Itching in Vaginal Area<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_209'><div class='gchoice gchoice_2_209_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.1' type='checkbox'  value='Present'  id='choice_2_209_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_209_1' id='label_2_209_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_209_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_209.2' type='checkbox'  value='Past'  id='choice_2_209_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_209_2' id='label_2_209_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_208\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_208\"><legend class='gfield_label gfield_label_before_complex'  >Hot Flashes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_208'><div class='gchoice gchoice_2_208_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_208.1' type='checkbox'  value='Present'  id='choice_2_208_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_208_1' id='label_2_208_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_208_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_208.2' type='checkbox'  value='Past'  id='choice_2_208_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_208_2' id='label_2_208_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_211\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_211\"><legend class='gfield_label gfield_label_before_complex'  >Vaginal Infections<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_211'><div class='gchoice gchoice_2_211_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.1' type='checkbox'  value='Present'  id='choice_2_211_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_211_1' id='label_2_211_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_211_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_211.2' type='checkbox'  value='Past'  id='choice_2_211_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_211_2' id='label_2_211_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_213\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_213\"><legend class='gfield_label gfield_label_before_complex'  >Cysts, Fibroids<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_213'><div class='gchoice gchoice_2_213_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.1' type='checkbox'  value='Present'  id='choice_2_213_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_213_1' id='label_2_213_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_213_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.2' type='checkbox'  value='Past'  id='choice_2_213_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_213_2' id='label_2_213_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_212\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_212\"><legend class='gfield_label gfield_label_before_complex'  >Sexually Transmitted Diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_212'><div class='gchoice gchoice_2_212_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.1' type='checkbox'  value='Present'  id='choice_2_212_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_212_1' id='label_2_212_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_212_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.2' type='checkbox'  value='Past'  id='choice_2_212_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_212_2' id='label_2_212_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_214\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_214\"><h4>Male History<\/h4><\/div><fieldset id=\"field_2_215\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_215\"><legend class='gfield_label gfield_label_before_complex'  >Prostate problems<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_215'><div class='gchoice gchoice_2_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Present'  id='choice_2_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_215_1' id='label_2_215_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='Past'  id='choice_2_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_215_2' id='label_2_215_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_217\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_217\"><legend class='gfield_label gfield_label_before_complex'  >Pain or Discomfort in Genital Area<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_217'><div class='gchoice gchoice_2_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Present'  id='choice_2_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_217_1' id='label_2_217_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='Past'  id='choice_2_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_217_2' id='label_2_217_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_219\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_219\"><legend class='gfield_label gfield_label_before_complex'  >Low Libido<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_219'><div class='gchoice gchoice_2_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Present'  id='choice_2_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_219_1' id='label_2_219_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Past'  id='choice_2_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_219_2' id='label_2_219_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_216\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_216\"><legend class='gfield_label gfield_label_before_complex'  >Difficulty Maintaining an Erection<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_216'><div class='gchoice gchoice_2_216_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.1' type='checkbox'  value='Present'  id='choice_2_216_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_216_1' id='label_2_216_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_216_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.2' type='checkbox'  value='Past'  id='choice_2_216_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_216_2' id='label_2_216_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_218\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_218\"><legend class='gfield_label gfield_label_before_complex'  >Pain, Lump, or Mass in testicles<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_218'><div class='gchoice gchoice_2_218_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.1' type='checkbox'  value='Present'  id='choice_2_218_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_218_1' id='label_2_218_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_218_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.2' type='checkbox'  value='Past'  id='choice_2_218_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_218_2' id='label_2_218_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_222\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_222\"><legend class='gfield_label gfield_label_before_complex'  >Discharge from Penis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_222'><div class='gchoice gchoice_2_222_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.1' type='checkbox'  value='Present'  id='choice_2_222_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_222_1' id='label_2_222_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_222_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.2' type='checkbox'  value='Past'  id='choice_2_222_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_222_2' id='label_2_222_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_221\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_221\"><legend class='gfield_label gfield_label_before_complex'  >Sexually Transmitted Disease(s)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_221'><div class='gchoice gchoice_2_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Present'  id='choice_2_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_221_1' id='label_2_221_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='Past'  id='choice_2_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_221_2' id='label_2_221_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_220\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_220\"><legend class='gfield_label gfield_label_before_complex'  >Infertility<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_220'><div class='gchoice gchoice_2_220_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.1' type='checkbox'  value='Present'  id='choice_2_220_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_220_1' id='label_2_220_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_220_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.2' type='checkbox'  value='Past'  id='choice_2_220_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_220_2' id='label_2_220_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_223\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_223\"><label class='gfield_label' for='input_2_223' >Age Periods Began<\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_2_223' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_226\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_226\"><label class='gfield_label' for='input_2_226' >Duration of Periods:<\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_2_226' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_2_225\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_225\"><label class='gfield_label' for='input_2_225' >Length of Cycle:<\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_2_225' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_224\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_224\"><label class='gfield_label' for='input_2_224' >Last Menstrual Period<\/label><div class='ginput_container ginput_container_text'><input name='input_224' id='input_2_224' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><fieldset id=\"field_2_227\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_227\"><legend class='gfield_label gfield_label_before_complex'  >Amount of Plow<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_227'><div class='gchoice gchoice_2_227_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.1' type='checkbox'  value='Light'  id='choice_2_227_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_227_1' id='label_2_227_1'>Light<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_227_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.2' type='checkbox'  value='Moderate'  id='choice_2_227_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_227_2' id='label_2_227_2'>Moderate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_227_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.3' type='checkbox'  value='Heavy'  id='choice_2_227_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_227_3' id='label_2_227_3'>Heavy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_228\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_228\"><label class='gfield_label' for='input_2_228' >Type of Birth Control:<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_2_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><fieldset id=\"field_2_229\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_229\"><legend class='gfield_label gfield_label_before_complex'  >Any Abnormal PAPs:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_229'><div class='gchoice gchoice_2_229_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.1' type='checkbox'  value='Yes'  id='choice_2_229_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_229_1' id='label_2_229_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_229_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_229.2' type='checkbox'  value='No'  id='choice_2_229_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_229_2' id='label_2_229_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_230\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_230\"><label class='gfield_label' for='input_2_230' >How Long ?<\/label><div class='ginput_container ginput_container_text'><input name='input_230' id='input_2_230' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_2_231\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_231\"><label class='gfield_label' for='input_2_231' >Pregnancies:<\/label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_2_231' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_233\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_233\"><label class='gfield_label' for='input_2_233' >Miscarriages:<\/label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_2_233' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_232\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_232\"><label class='gfield_label' for='input_2_232' >Children:<\/label><div class='ginput_container ginput_container_text'><input name='input_232' id='input_2_232' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 7;\"><\/div><div id=\"field_2_234\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_234\"><label class='gfield_label' for='input_2_234' >Date of last PAP smear:<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_2_234' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_235\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_235\"><legend class='gfield_label gfield_label_before_complex'  >Birth Control Pill Use:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_235'><div class='gchoice gchoice_2_235_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.1' type='checkbox'  value='Yes'  id='choice_2_235_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_235_1' id='label_2_235_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_235_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_235.2' type='checkbox'  value='No'  id='choice_2_235_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_235_2' id='label_2_235_2'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_236\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_236\"><h4>Diet<\/h4><\/div><fieldset id=\"field_2_237\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_237\"><legend class='gfield_label gfield_label_before_complex'  >Cigarettes __ packs per day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_237'><div class='gchoice gchoice_2_237_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.1' type='checkbox'  value='Present'  id='choice_2_237_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_237_1' id='label_2_237_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_237_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.2' type='checkbox'  value='Past'  id='choice_2_237_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_237_2' id='label_2_237_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_240\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_240\"><legend class='gfield_label gfield_label_before_complex'  >Coffee or Black tea __ cups per day<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_240'><div class='gchoice gchoice_2_240_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.1' type='checkbox'  value='Present'  id='choice_2_240_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_240_1' id='label_2_240_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_240_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_240.2' type='checkbox'  value='Past'  id='choice_2_240_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_240_2' id='label_2_240_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_238\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_238\"><legend class='gfield_label gfield_label_before_complex'  >Alcohol __ per week<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_238'><div class='gchoice gchoice_2_238_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.1' type='checkbox'  value='Present'  id='choice_2_238_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_238_1' id='label_2_238_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_238_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_238.2' type='checkbox'  value='Past'  id='choice_2_238_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_238_2' id='label_2_238_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_239\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_239\"><legend class='gfield_label gfield_label_before_complex'  >Drugs __ per week<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_239'><div class='gchoice gchoice_2_239_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.1' type='checkbox'  value='Present'  id='choice_2_239_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_239_1' id='label_2_239_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_239_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_239.2' type='checkbox'  value='Past'  id='choice_2_239_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_239_2' id='label_2_239_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_241\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_241\"><legend class='gfield_label gfield_label_before_complex'  >Drugs __ per week<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_241'><div class='gchoice gchoice_2_241_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.1' type='checkbox'  value='Present'  id='choice_2_241_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_241_1' id='label_2_241_1'>Present<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_241_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_241.2' type='checkbox'  value='Past'  id='choice_2_241_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_241_2' id='label_2_241_2'>Past<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_242\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_242\"><h4>FAMILY HISTORY<\/h4><\/div><div id=\"field_2_243\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_243\"><label class='gfield_label' for='input_2_243' >Number of meals per day<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_2_243' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_245\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_245\"><label class='gfield_label' for='input_2_245' >Number of snacks per day<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_2_245' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_244\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_244\"><label class='gfield_label' for='input_2_244' >Number of glasses of water per day<\/label><div class='ginput_container ginput_container_text'><input name='input_244' id='input_2_244' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_2_246\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_246\"><legend class='gfield_label gfield_label_before_complex'  >Do you include these foods in your diet? (Please Circle)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_246'><div class='gchoice gchoice_2_246_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_246.1' type='checkbox'  value='Fast Foods'  id='choice_2_246_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_246_1' id='label_2_246_1'>Fast Foods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_246_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_246.2' type='checkbox'  value='Fried Foods'  id='choice_2_246_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_246_2' id='label_2_246_2'>Fried Foods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_246_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_246.3' type='checkbox'  value='Processed\/Packaged Food'  id='choice_2_246_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_246_3' id='label_2_246_3'>Processed\/Packaged Food<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_247\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_247\"><label class='gfield_label' for='input_2_247' >Do you avoid any foods<\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_2_247' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_248\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_248\"><label class='gfield_label' for='input_2_248' >Vitamins\/Supplements\/Herbs (Please List)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_248' id='input_2_248' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_249\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_249\"><label class='gfield_label' for='input_2_249' >Prescription\/Over Counter Medications (Please List)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_249' id='input_2_249' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_250\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_250\"><label class='gfield_label' for='input_2_250' >Allergies<\/label><div class='ginput_container ginput_container_text'><input name='input_250' id='input_2_250' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_251\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_251\"><h4>Habits<\/h4><\/div><div id=\"field_2_252\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_252\"><label class='gfield_label' for='input_2_252' >How many times in the last<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_2_252' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_253\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_253\"><label class='gfield_label' for='input_2_253' >How many times in the last 3 years ?<\/label><div class='ginput_container ginput_container_text'><input name='input_253' id='input_2_253' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_2_254\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_254\"><label class='gfield_label' for='input_2_254' >Accidents, Surgeries, Serious Illnesses<\/label><div class='ginput_container ginput_container_text'><input name='input_254' id='input_2_254' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_2_255\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_255\"><label class='gfield_label' for='input_2_255' >Date of Most Recent Labwork:<\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_2_255' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_2_256\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_256\"><h4>History of Antibiotic Use<\/h4><\/div><fieldset id=\"field_2_257\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_257\"><legend class='gfield_label gfield_label_before_complex'  >Alcoholism or Other Drug Abuse<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_257'><div class='gchoice gchoice_2_257_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.1' type='checkbox'  value='Mother'  id='choice_2_257_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_257_1' id='label_2_257_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_257_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.2' type='checkbox'  value='Father'  id='choice_2_257_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_257_2' id='label_2_257_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_257_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.3' type='checkbox'  value='Siblings'  id='choice_2_257_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_257_3' id='label_2_257_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_257_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_257.4' type='checkbox'  value='Grand Parents'  id='choice_2_257_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_257_4' id='label_2_257_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_261\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_261\"><legend class='gfield_label gfield_label_before_complex'  >Arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_261'><div class='gchoice gchoice_2_261_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_261.1' type='checkbox'  value='Mother'  id='choice_2_261_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_261_1' id='label_2_261_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_261_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_261.2' type='checkbox'  value='Father'  id='choice_2_261_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_261_2' id='label_2_261_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_261_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_261.3' type='checkbox'  value='Siblings'  id='choice_2_261_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_261_3' id='label_2_261_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_261_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_261.4' type='checkbox'  value='Grand Parents'  id='choice_2_261_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_261_4' id='label_2_261_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_260\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_260\"><legend class='gfield_label gfield_label_before_complex'  >Cancer, Leukemia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_260'><div class='gchoice gchoice_2_260_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.1' type='checkbox'  value='Mother'  id='choice_2_260_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_260_1' id='label_2_260_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_260_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.2' type='checkbox'  value='Father'  id='choice_2_260_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_260_2' id='label_2_260_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_260_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.3' type='checkbox'  value='Siblings'  id='choice_2_260_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_260_3' id='label_2_260_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_260_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_260.4' type='checkbox'  value='Grand Parents'  id='choice_2_260_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_260_4' id='label_2_260_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 8;\"><\/div><fieldset id=\"field_2_259\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_259\"><legend class='gfield_label gfield_label_before_complex'  >Depression, Other Mental Diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_259'><div class='gchoice gchoice_2_259_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_259.1' type='checkbox'  value='Mother'  id='choice_2_259_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_259_1' id='label_2_259_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_259_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_259.2' type='checkbox'  value='Father'  id='choice_2_259_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_259_2' id='label_2_259_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_259_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_259.3' type='checkbox'  value='Siblings'  id='choice_2_259_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_259_3' id='label_2_259_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_259_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_259.4' type='checkbox'  value='Grand Parents'  id='choice_2_259_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_259_4' id='label_2_259_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_262\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_262\"><legend class='gfield_label gfield_label_before_complex'  >Diabetes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_262'><div class='gchoice gchoice_2_262_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.1' type='checkbox'  value='Mother'  id='choice_2_262_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_262_1' id='label_2_262_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_262_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.2' type='checkbox'  value='Father'  id='choice_2_262_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_262_2' id='label_2_262_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_262_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.3' type='checkbox'  value='Siblings'  id='choice_2_262_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_262_3' id='label_2_262_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_262_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_262.4' type='checkbox'  value='Grand Parents'  id='choice_2_262_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_262_4' id='label_2_262_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_258\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_258\"><legend class='gfield_label gfield_label_before_complex'  >Asthma, Emphysema<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_258'><div class='gchoice gchoice_2_258_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_258.1' type='checkbox'  value='Mother'  id='choice_2_258_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_258_1' id='label_2_258_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_258_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_258.2' type='checkbox'  value='Father'  id='choice_2_258_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_258_2' id='label_2_258_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_258_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_258.3' type='checkbox'  value='Siblings'  id='choice_2_258_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_258_3' id='label_2_258_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_258_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_258.4' type='checkbox'  value='Grand Parents'  id='choice_2_258_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_258_4' id='label_2_258_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 8;\"><\/div><fieldset id=\"field_2_263\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_263\"><legend class='gfield_label gfield_label_before_complex'  >Heart Disease\/High Blood Pressure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_263'><div class='gchoice gchoice_2_263_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.1' type='checkbox'  value='Mother'  id='choice_2_263_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_263_1' id='label_2_263_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_263_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.2' type='checkbox'  value='Father'  id='choice_2_263_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_263_2' id='label_2_263_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_263_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.3' type='checkbox'  value='Siblings'  id='choice_2_263_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_263_3' id='label_2_263_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_263_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_263.4' type='checkbox'  value='Grand Parents'  id='choice_2_263_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_263_4' id='label_2_263_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_265\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_265\"><legend class='gfield_label gfield_label_before_complex'  >Kidney Disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_265'><div class='gchoice gchoice_2_265_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.1' type='checkbox'  value='Mother'  id='choice_2_265_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_265_1' id='label_2_265_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_265_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.2' type='checkbox'  value='Father'  id='choice_2_265_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_265_2' id='label_2_265_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_265_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.3' type='checkbox'  value='Siblings'  id='choice_2_265_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_265_3' id='label_2_265_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_265_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_265.4' type='checkbox'  value='Grand Parents'  id='choice_2_265_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_265_4' id='label_2_265_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_264\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_264\"><legend class='gfield_label gfield_label_before_complex'  >Thyroid Disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_2_264'><div class='gchoice gchoice_2_264_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.1' type='checkbox'  value='Mother'  id='choice_2_264_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_264_1' id='label_2_264_1'>Mother<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_264_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.2' type='checkbox'  value='Father'  id='choice_2_264_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_264_2' id='label_2_264_2'>Father<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_264_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.3' type='checkbox'  value='Siblings'  id='choice_2_264_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_264_3' id='label_2_264_3'>Siblings<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_264_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.4' type='checkbox'  value='Grand Parents'  id='choice_2_264_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_264_4' id='label_2_264_4'>Grand Parents<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div class=\"spacer gfield\" style=\"grid-column: span 8;\"><\/div><div id=\"field_2_266\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_266\"><h2 class=\"gat-heading\">The Ellenburg Center For Natural Medicine, Inc.<br>\nAnchorage, Alaska 99508<\/h2>\n\n<div class=\"num-form\">\n<a href=\"tel:907-563-2366\"><span>Phone:<\/span> 907-563-2366<\/a>\n\n<a href=\"tel:907-563-2365\"><span>Fax:<\/span> 907-563-2365<\/a>\n<\/div>\n\n<div class=\"pat-info\">\n<h3>Patient Information Sheet<br>\n(Please Print Clearly)<\/h3>\n<\/div><\/div><div id=\"field_2_267\"  class=\"gfield gfield--width-seven-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_267\"><label class='gfield_label' for='input_2_267' >Signed<\/label><div class='ginput_container ginput_container_text'><input name='input_267' id='input_2_267' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_269\"  class=\"gfield gfield--width-five-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_269\"><label class='gfield_label' for='input_2_269' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_269' id='input_2_269' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_269_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_269_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_269' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_268\"  class=\"gfield gfield--width-seven-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_268\"><label class='gfield_label' for='input_2_268' >WTINESS<\/label><div class='ginput_container ginput_container_text'><input name='input_268' id='input_2_268' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_270\"  class=\"gfield gfield--width-five-twelfths field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_270\"><label class='gfield_label' for='input_2_270' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_270' id='input_2_270' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_270_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_270_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_270' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_271\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_271\"><h2 class=\"gat-heading\">RECEIPT OF NOTICE OF PRIVACY POLICIES & CONSENT FORM<\/h2>\n\n<h3>Dr. EUenburg Center for Natural Medicine, Inc.\n3500 Latouche St Suite 360. Anchorage, Alaska 99508<\/h3>\n\n<div class=\"num-form\">\n<a href=\"tel:907-563-2366\"><span>Phone:<\/span> 907-563-2366<\/a>\n\n<a href=\"tel:907-563-2365\"><span>Fax:<\/span> 907-563-2365<\/a>\n\n<a href=\"mailto:mellenburg@acsalaska.net\"><span>E-mail:<\/span> mellenburg@acsalaska.net<\/a>\n<\/div>\n<\/div><div id=\"field_2_272\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_272\"><label class='gfield_label' for='input_2_272' >Patient Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_272' id='input_2_272' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_274\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_274\"><label class='gfield_label' for='input_2_274' >Patient Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_274' id='input_2_274' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_273\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_273\"><label class='gfield_label' for='input_2_273' >Patient Phone Number<\/label><div class='ginput_container ginput_container_text'><input name='input_273' id='input_2_273' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_275\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_275\"><p>\n1n the course ofproviding service to you, we create. receive and store health information that\nidentifies you. It is often necessazyto use and disclose this health information in orderto treat\nyou, to obtain payment for our services and to conduct health care operations involving our\noffice.<br><br>\nThe Notice of Privacy Practices you have been given describes these uses and disclosures in\ndetail. You are free to refer to this notice at anytime before you sign this form.\u00b7 As described in our No.ice of Privacy Practices, the use and disclosure of your health. information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for\nprocessing claims or obtaining payment; {2) our submission ofclaims to third-paify payers or\ninsurers for claims review, determination ofbenefits and payment; (3) our submission of your\nhealth information to auditors hlredby third-pa.tfy payers and insurers; and (4) other aspects of\npayment described in our Notice of Privacy Practices.<br><br>\nOur Notice of Privacy Practice will be updated whenever our privacy practices change.<br><br>\nWhen you sign this consent document, you signify that you agree that we can and will use and\ndisclose your health information to treat you, to obtain payment for our services and tQ perform\nhealthcare operations.\nYou also signify that yon have received a copy of our Notice of Privacy Practices.\nYou have the right to ask us to restrict the uses or disclosures made for purposes of treatment \ufffdpayment or healthcare operations\ufffd but as described on our Notice of Privacy Practices, we are not\nobligated to agree io these suggested restrictions. If we do agree, however, the restrictions are\nbinding on us.\nOur Notice of Privacy Practices describes how to ask for a restriction.\nI have read this document and understand it I consent to the use and disclosure of my health\n9\ninformation for purposes of treatment, payment and healthcare operations.. .\nI acknowledge that I have received the Notice of Privacy Practices from The Dr. EIJenburg\nCenter For Natural Medicine, Inc\n\n<\/p><\/div><div id=\"field_2_276\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_276\"><label class='gfield_label' for='input_2_276' >Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_276' id='input_2_276' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_277\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_277\"><label class='gfield_label' for='input_2_277' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_277' id='input_2_277' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_277_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_277_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_277' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_278\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_278\">If signing as a personal representative of the patient., describe the relationship to the patient and the source of authority to sign this fonn: <\/div><div id=\"field_2_279\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_279\"><label class='gfield_label' for='input_2_279' >Relationship to Patient<\/label><div class='ginput_container ginput_container_text'><input name='input_279' id='input_2_279' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_2_280\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_280\"><label class='gfield_label' for='input_2_280' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_280' id='input_2_280' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_280_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_280_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_280' class='gform_hidden' value='http:\/\/websitedemolynks.co\/markianbabij\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_281\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_281\"> <h1 class=\"last__head\">NOTICE OF PRIVACY PRACTICES <\/h1>\n\t<p>THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. <\/p>\n\t<h3>OUR PLEDGE REGARDING MEDICAL INFORMATION<\/h3>\n\t<p>The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medic<\/p>\n\t<h3>OUR LEGAL DUTY<\/h3>\n\t<p class=\"inner__para\">Law Requires us to:<\/p>\n\t<ul>\n\t\t<li>Keep your medical information private.<\/li>\n\t\t<li>Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information<\/li>\n\t\t<li>Follow the terms of the current notice.<\/li>\n\t<\/ul>\n\t<p class=\"\">We have the right to: <\/p>\n\t<ul>\n\t\t<li>Change our privacy practice and the terms of this notice at any time, provide that the changes are permitted by law. <\/li>\n\t\t<li>. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.\n<\/li>\n\t<\/ul>\n\t<p class=\"inner__para\">Notice of change to privacy practice:<\/p>\n\t<p>1. Before we make an important change in our privacy practice, we will change this notice and make the new notice available upon request. \n<\/p>\n    <h3>USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION<\/h3>\n\t<p>The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed.\nHowever, we have listed all the different ways we are permitted to use and disclose medical information. We will not use or disclose\nyour medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization\nyou provide may be revoked at any time by writing to us at the address provided at the end of this notice. \n<\/p>\n<p class=\"inner__para\">FOR TREATMENT:<\/p>\n<p>We may use medical information about you to provide you with medical treatment or services. We may disclose medical\ninformation about you to your doctors, nurses, technicians, medial students, or other people who are taking care of you. We may also share medical\ninformation about you to your other health care providers to assist them in treating you.<\/p>\n<p class=\"inner__para\">FOR PAYMENT:<\/p>\n<p> We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The\ninformation on or accompanying the bill may include your medical information.<\/p>\n<p class=\"inner__para\">FOR HEAL TH CARE OPERATIONS:<\/p>\n<p>We may use and disclose your medical information for our health care operations. This might include\nmeasuring and improving quality, evaluating the performance of employees. Conducting training programs, getting the accreditation, certificates,\nlicenses and credentials we need to serve you.<\/p>\n<p class=\" inner__para\">ADDITIONAL USES AND DISCLOSURES:<\/p>\n<p>In addition to using and disclosing your medical information for treatment, payment, and health care\noperations, we may use and disclose medical information for the following purposes.<\/p>\n<p class=\" inner__para\">Facility Directory:<\/p>\n<p>Unless you notify us that you object, the following medical information about will be placed in our facility directories: your name;\nyour location in our facility; your condition described in general terms; your religious affiliation, if any. We may disclose this information to members of\nthe clergy or, except for religious affiliation, to others who contact us for information about your name. <\/p>\n<p class=\"inner__para\">Notification<\/p>\n<p>: We may use and disclose medical information to notify or help notify: a family member, your personal representative or another person\nresponsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission is\npossible before we share, or give you the opportunity to refuse permission, In case of emergency, and if you are not able to give or refuse permission,\nwe will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our\nprofessional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-rays or medical\ninformation for you <\/p>\n<p class=\"inner__para \">Disaster Relief:<\/p>\n<p>We may share medical information with a public or private organization or persona who can legally assist in disaster relief efforts.<\/p>\n<p class=\"inner__para \">Fundraising<\/p>\n<p>We may provide medial information to one of our affiliated fundraising foundations to contact you for fundraising purpose. We will limit\nour use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials,\nwe will provide you a description of how you may choose not to receive future fundraising communications. <\/p>\n<p class=\"inner__para \">Research in Limited Circumstances: <\/p>\n<p>We may use medical information for research purpose in limited circumstances\nwhere the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of\nmedical information. <\/p>\n<p class=\"inner__para\"> Funeral Director, Coroner, Medical Examiner<\/p>\n<p>To help them carry out their duties, we may share the medical information of a person that has died with a coroner, medical examiner, funeral director, or an organ procurement organization. <\/p>\n<p class=\"inner__para \">Specialized Government functions<\/p>\t\n<p>Subject to certain requirements, we may digciose or use hesith information for military personnel and\nveterans, for national socurtty and intligence actvites, fo protective services of the President and others, for medical suitabilty determinations for\nthe Department of stat, for correctional Institution and othr law enforcement custodial iuations, and or government programs.<\/p>\n\n<p class=\"inner__para\">Court Orders and Judicial and Administrative Proceedings:<\/p>\n<p>We may disclose medical information in response to a court or administrative\norder, subpoena, discovery rogues? or other lawful process, under certain circumstances. Under imited Gircumstances, such as a cour order, warrant,\ngrand jury subpoena, we may sharg your medical information with the law enforcement officials. We may share limited information with a law\nforcement concoming the medical information of a suspect fugitive, materia witness, crime victim of issing person. We may share the medical\ninformation of an inmate or other person in lawful Custody witha law enforcement offical or corroctional institution under cerain circumstances.<\/p>\n<p class=\" inner__para\">Public Health Activities:<\/p>\n<p>As required by law, we may discos your medical information to public health o legal authorites charged wh\nproventing or controling disease, injury or disablfy, including child abuse or neglect. We may also disclose your medical information o persons.\nsubject fo jurisdiction of the Food and Drug Adminstration for purpose of reporting adverse events associated with product defects or problems, to\n\u2018enable product recalls, ropairs of replacements, to track products, or to conduct activiles required by the Food and Drug Administration, We may also,\nWhen we are authorized by law 10 do 50, nofy a person who may have been exposed to 2 communicable disease of otherwise be at isk of\ncontracting or spreading a disease or condition.<\/p>\n<p class=\"inner__para \">Victims of Abuse, Neglect, or Domestic Violence:<\/p>\n<p>We may use and disclose medical information to appropriats authorities if we reasonably\nbelieve that you are a possible victim of abuse, neglect, or domestic violence of the possible icin of other crimes. Wo may share your medical\ninformation fis necessary to prevent a serious that to your health or safaty of others. Wo may sharo medical information when necessary o help\nlaw enforcement officals capture a person who has adritied to being part of a rime or has escaped from legal custody.\n<\/p>\n<p class=\"inner__para \">Workers Compensation: <\/p>\n<p> We may disclose medical information when authorized or necessary to comply with laws relating 0 workers compensation or other smiar programs. <\/p>\n<p class=\"inner__para \">Health Oversight Activities:<\/p>\n<p>We may disciose medical information to an agency providing health oversight for oversight acivies authorized by\nTaw, including audits, ci, administrative, or criminal Investigations or proceedings, inspection, ensure or discipinary actions, or oher authorized\nactivites.<\/p>\n<p class=\"inner__para \">Law Enforcement:<\/p>\n<p>Undo ceain circumstances, we iscoso heath information o law enforcement ffals. These cicumsances include\nreporting roquired by certain laws (such 2s the reporting of certain type of wounds), pursuant to certain subpoenas or court orders, reporting limited\ninformation concoming Kenticatons and location atthe request of a law enorooment offical, reports rogarding suspected vicims of cimas at the\noquest of a aw enforcomont offical, eportng death, cimes on our premises, and cimes in omargencies.\n<\/p>\n<p class=\"inner__para \">Appointment Reminders: <\/p>\n<p>We may us and disclose medical information for purpose of sending you appointment postcards or otherwise reminding\nYou of your appointments.<\/p>\n\n<p class=\"inner__para\">Alternative and Additional Medical Services:<\/p>\n<p>We may use and disclose medical information o furnish you with information about heat related benefits and services that may be of interest 10 you. and to describe or recommend treatment altemnatives.<\/p>\n<h1 class=\"last__head\">YOUR INDIVIDUAL RIGHTS <\/h1>\n<p class=\"inner__para\">You Have a Right<\/p>\n<ul>\n<li>Look at o get copies of certain parts of your medical Information. You may request that we provide copies i a format other than photocopies. We\nwill ise the format you request unloss ii io practical fo us to do so. You must make your request in wring. You may get the form to request access.\nby using the contact information listed a the end of this notice. you requost copies, we wil charge you \u00a7 .35 cents for each page, and postage fou\nwant the copios mailed to you. Contact us using the information fisted at the end of this noios fo a ul explanation of our fee struciur.\n<\/li>\n<li> Receve a ist of all he imes we our business associates shared your medical information for purposes othr than treatment, payment, and health\naro operations and other specified exceptions<\/li>\n<li>Roguest that we replace additonal restrictions on ou uso or disclosure of your medical information. We are no required to agree fo these addional\nTestictons, but if we do, we illaide by our agreement (ex08p in the case of an emergency).<\/li>\n<li>Request that we communicate with you about your medica information by different means o to diferent locations. Your request that we\n\u2018communicate your medical information to you by diferent means or at dferent locations must be made in wring to the contact person fisted at the\n\u2018ond of tis notice.<\/li>\n<li>Request that we change cortain parts of your medica information. We may deny you request ff we did not create th information that you want\n\u2018changed or for certain thar reasons. It we deny your request, provide you a writen explanatn. You may respond with statement or disagreement.\nthat we will be added tothe information you waned changed. If we accept your request to change the information, we will make reasonable eforts to\ntell others, including peopl you name, of the change and to include the changes in any fture sharing of that information.<\/li>\n<li> you have received this notice electronically. and wish to receive a paper copy, you have the right to obiain a paper copy by making a request in\nwring tthe contact person fisted atthe end ofthis notice.<\/li>\n<\/ul>\n\n<h1 class=\"last__head\">QUESTIONS AND COMPLANTS <\/h1>\n<p>you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also subrit a writen complain to the U.S Department of health and Human Service. You may contact us to submit a complaint or submit requests involving any of Your rights In Section 4 of tis notice by writing to the folowing address.\n\nWe will provide you with the address to fil your complaint with the U.S Department of Health and Human Services. We will not retaliate in any way if\nYou choose to fie a complaint.<\/p>\n<\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button gfield--width-three-quarter' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} if( !jQuery(\"#gform_2\")[0].checkValidity || jQuery(\"#gform_2\")[0].checkValidity()){window[\"gf_submitting_2\"]=true;}  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsImQwYWEzODUyZDg0ZDk3NTVhZGFhOTEyYmEyYjJkOTk5Il0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>[\/vc_column][\/vc_row][\/vc_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_section][vc_row][vc_column][\/vc_column][\/vc_row][\/vc_section]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.4 - 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