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226  <template data-nitro-marker-id="7a9d3548e80899cec4f92435b677fe9c-1"></template> <div id="pum-542" role="dialog" aria-modal="false" class="pum pum-overlay pum-theme-528 pum-theme-default-theme popmake-overlay click_open" data-popmake="{&quot;id&quot;:542,&quot;slug&quot;:&quot;iv-general-anesthesia-implants&quot;,&quot;theme_id&quot;:528,&quot;cookies&quot;:[],&quot;triggers&quot;:[{&quot;type&quot;:&quot;click_open&quot;,&quot;settings&quot;:{&quot;extra_selectors&quot;:&quot;.IV-general-anesthesia-implants&quot;}}],&quot;mobile_disabled&quot;:null,&quot;tablet_disabled&quot;:null,&quot;meta&quot;:{&quot;display&quot;:{&quot;stackable&quot;:false,&quot;overlay_disabled&quot;:false,&quot;scrollable_content&quot;:false,&quot;disable_reposition&quot;:false,&quot;size&quot;:&quot;small&quot;,&quot;responsive_min_width&quot;:&quot;0%&quot;,&quot;responsive_min_width_unit&quot;:false,&quot;responsive_max_width&quot;:&quot;100%&quot;,&quot;responsive_max_width_unit&quot;:false,&quot;custom_width&quot;:&quot;640px&quot;,&quot;custom_width_unit&quot;:false,&quot;custom_height&quot;:&quot;380px&quot;,&quot;custom_height_unit&quot;:false,&quot;custom_height_auto&quot;:false,&quot;location&quot;:&quot;center top&quot;,&quot;position_from_trigger&quot;:false,&quot;position_top&quot;:&quot;100&quot;,&quot;position_left&quot;:&quot;0&quot;,&quot;position_bottom&quot;:&quot;0&quot;,&quot;position_right&quot;:&quot;0&quot;,&quot;position_fixed&quot;:false,&quot;animation_type&quot;:&quot;fade&quot;,&quot;animation_speed&quot;:&quot;350&quot;,&quot;animation_origin&quot;:&quot;center top&quot;,&quot;overlay_zindex&quot;:false,&quot;zindex&quot;:&quot;1999999999&quot;},&quot;close&quot;:{&quot;text&quot;:&quot;&quot;,&quot;button_delay&quot;:&quot;0&quot;,&quot;overlay_click&quot;:false,&quot;esc_press&quot;:false,&quot;f4_press&quot;:false},&quot;click_open&quot;:[]}}"> <div id="popmake-542" class="pum-container popmake theme-528 pum-responsive pum-responsive-small responsive size-small"> <div class="pum-content popmake-content" tabindex="0"> <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_15'><div id='gf_15' class='gform_anchor' tabindex='-1'></div> <div class='gform_heading'> <p class='gform_required_legend'>&quot;<span class="gfield_required gfield_required_asterisk">*</span>&quot; indicates required fields</p> </div><form method='post' enctype='multipart/form-data' id='gform_15' action='/locations/#gf_15' data-formid='15' novalidate> <div id='gf_progressbar_wrapper_15' class='gf_progressbar_wrapper' data-start-at-zero=''> <p class="gf_progressbar_title">Step <span class='gf_step_current_page'>1</span> of <span class='gf_step_page_count'>6</span><span class='gf_step_page_name'></span> </p> <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'> <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%'><span>16%</span></div> </div></div> <div class='gform-body gform_body'><div id='gform_page_15_1' class='gform_page ' data-js='page-field-id-0'> <div class='gform_page_fields'><div id='gform_fields_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_2" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IMPLANT SURGERY</h5> <h5>INFORMATION AND CONSENT FORM</h5> <p></p><ol> <li>I have been informed of and I understand the purpose and nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.</li> <li>My doctor has carefully examined my mouth and explained alternatives to this treatment have been explained to me. I have either tried or have considered these options and have concluded that an implant is my treatment of choice to secure the tooth or denture to be replaced.</li> <li>I have further been informed of the possible risks and complications involved with surgery, drugs (allergic or adverse reactions) and anesthesia. Such complications include pain, swelling, infection, bruising. Numbness of the lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Other possible risks are injury to other teeth, bone fractures, sinus perforation, delayed healing, rejection of the implant.</li> <li>It has been explained to me that in some instances implants fail and must be removed. The success rate of dental implant surgery is very high but dentistry is not an exact science and no guarantee or assurance as to the outcome of the result of treatment can be made.</li> <li>I understand that if nothing is done any of the following could occur: loss of bone and/or gum tissue, inflammation of the gums, infection, loose teeth, loss of teeth, and the occurrence or reoccurrence of Temporomandibular (jaw) joint symptoms</li> <li>I understand that excessive smoking, alcohol, or sugar may affect healing and may limit the success of the implant. I agree to follow my doctors home care instructions. I agree to report to my doctor for regular examinations as instructed.</li> <li> To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, reported any bleeding disorders or any other condition related to my health</li> <li>I consent to the photographing filming videotaping of the procedure to be performed provided my identity is not revealed.</li> <li>I request and authorize the dental services for me, including implants and other surgical procedures as deemed necessary to accomplish the placement of the implants. I fully understand that during and following the procedure conditions may become apparent that warrant additional or alternative treatments pertinent o the success of the comprehensive treatment. I also approve any modification in the design or materials if it is felt to be in my best interest.</li> <li>The fees for this treatment plan and the payment plan have been explained to me and I have approved them.</li></ol><p></p></div><fieldset id="field_15_34" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFORMATION AND CONSENT FORM</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_34'><div class='gchoice gchoice_15_34_1'> <input class='gfield-choice-input' name='input_34.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_15_34_1' /> <label for='choice_15_34_1' id='label_15_34_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_15_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_15_2' class='gform_page' data-js='page-field-id-7' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_15_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_9" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h3> </div><div id="field_15_57" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_15_59" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_15_35" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_35'><div class='gchoice gchoice_15_35_1'> <input class='gfield-choice-input' name='input_35.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_15_35_1' /> <label for='choice_15_35_1' id='label_15_35_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_15_27' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_15_27' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_15_3' class='gform_page' data-js='page-field-id-27' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_15_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_16" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p><b class="nitro-lazy">Ontario’s Narcotics Strategy</b></p> <p><b>List Of Approved Forms Of Identification</b></p> <p> </p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul><p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li>Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Canadian Immigration Identification Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>Royal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_15_36" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_36'><div class='gchoice gchoice_15_36_1'> <input class='gfield-choice-input' name='input_36.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_15_36_1' /> <label for='choice_15_36_1' id='label_15_36_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_15_28' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_15_28' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_15_4' class='gform_page' data-js='page-field-id-28' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_15_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_19" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST OP FOR DENTAL IMPLANTS</h5> <p></p><ol> <li><b>Smoking:</b> Do not smoke. Patients who smoke will experience delayed healing and greater discomfort and are at higher risk for infection. In addition smoking will compromise your result.</li> <li><b>Medication:</b> It is important to follow the instructions written on your prescription. If you experience any unfavourable reactions such as nausea, vomiting, diarrhea, rash, etc. call the doctor.</li> <li><b>Rest:</b> Do not plan on any activities for the remainder of the day. Avoid any strenuous activity for 1 week following surgery.</li> <li><b>Pain:</b> Some discomfort is expected once the anesthetic wears off. If you were prescribed post-operative pain medication, begin taking it before the anesthetic wears off to minimize discomfort. Ibuprofen is an effective pain medication and also reduces swelling. It can be taken for the first 3-4 days on a continuous basis (4 times per day) with a maximum dose of 3 grams per day. You may take Ibuprofen in addition to and at the same time as a prescribed narcotic such as Tylenol #2 or #3.</li> <li><b>Swelling:</b> Some swelling may occur the day after surgery and will generally persist for 24-36 hours, then diminish.Swelling can be minimized by placing an ice pack on the outside of the face over the surgical site alternating on and off in 10 minute intervals. You should do this forthe 24 hours following your surgery.</li> <li><b>Bleeding:</b> There should be no outright bleeding after surgery, though a slight pinkish colour to your saliva is common. If bleeding occurs, place a moistened non herbal tea bag over the area and apply gentle pressure. Continue this for 20 minutes. If bleeding persists call the doctor.</li> <li> <b>Rinsing:</b> Following your surgery you should rinse with warm salt water for the next 24 hours. Do not brush or floss or water pik in the area involved in the surgery. If you have been prescribed mouthwash use it twice daily until the stiches are removed. Make sure there is no toothpaste in your mouth when rinsing.</li> <li><b>Diet:</b> It is important to maintain a normal healthy diet. Do not drink any hot drinks for the first 24 hours. The 4 days following surgery eat soft foods (oatmeal, cottage cheese, eggs, avocado, fruit and vegetable juices) Try to do 
226your chewing on the opposite site of your mouth from where the surgery took place. Avoid any coarse foods such as seeds, nuts, chips, popcorn etc. . . . It may be necessary to maintain a liquid diet for a few days. Increase your fluid intake during this time. Avoid using a straw for 4 days.</li> </ol><p></p> <h5 style="text-align:center">Dr. Brian Kumer<br /><a href="tel:+4166050008">(416) 605-0008</a> </h5></div><fieldset id="field_15_37" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST OP FOR DENTAL IMPLANTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_37'><div class='gchoice gchoice_15_37_1'> <input class='gfield-choice-input' name='input_37.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_15_37_1' /> <label for='choice_15_37_1' id='label_15_37_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_15_29' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_15_29' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_15_5' class='gform_page' data-js='page-field-id-29' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_15_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_22" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IV General Anesthesia consent form</h5> <p>I authorize Dr. Stephen Ing and associates/assistants of his choice to perform intravenous sedation/anesthesia, as a part of my dental procedure. Additionally, I authorize the performance of any other procedure that in the judgment of Dr. Ing may be necessary for my well-being, including such interventions that are considered medically advisable to remedy conditions encountered during the proposed procedure.</p> <p>I am satisfied with my understanding of the nature of the anesthesia plan of care and the more common drawbacks and complications associated with it. These may include, but are not limited to: swelling, bleeding or discomfort at the site of intravenous insertion; allergic reactions to the anesthetic agents used; nausea and/or vomiting; prolonged recovery from anesthesia; post-operative disorientation/delirium (temporary); aspiration of stomach contents (rare); sore throat; fractured teeth; sore/bleeding nose. There is also a very rare potential for serious harm, including respiratory and cardiac arrest which can result in brain damage or death. I understand the risks, complications, and potential benefits of anesthesia. I have been given ample opportunity to discuss alternative methods of treatment, if any, along with their risks and benefits. No warranty or guarantee has been made as to the outcome of the anesthesia plan of care.</p> <p>I understand that in some instances where a general anesthetic (ie, completely asleep/unconscious) has been specifically requested, Dr. Ing may use a breathing tube to ensure that the patient's airway remains unobstructed during the procedure. In these instances, there is an increased chance of a temporary sore throat or in much rarer circumstances, physical trauma to the airway.</p> <p>I understand that anesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Ing of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation/anesthetic. For similar reasons, I understand that I must inform Dr. Ing if I am a nursing mother.</p> <p>I understand and agree to the following post-anesthetic instructions: </p><ol> <li>I will not drive a car or operate machinery for at least 24 hours, longer if drowsiness or dizziness persists.</li> <li>I will not drink alcoholic beverages for a minimum of 24 hours after the procedure.</li> <li>I will be in the care of a responsible adult until I am fully alert.</li> </ol> <p></p></div><fieldset id="field_15_38" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>IV General Anesthesia consent form</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_15_38'><div class='gchoice gchoice_15_38_1'> <input class='gfield-choice-input' name='input_38.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_15_38_1' /> <label for='choice_15_38_1' id='label_15_38_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_15_30' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_15_30' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_15_6' class='gform_page' data-js='page-field-id-30' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_15_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_15_25" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>Pre And Post-anesthesia Instructions</h5> <h5>PRE-OPERATIVE INSTRUCTIONS FOR PATIENTS WHO WILL BE RECEIVING SEDATION OR ANESTHESIA</h5> <p> </p><ol> <li>Nothing to eat or drink (including water) for 8 hours before the procedure.</li> <li>The only exception to the above instruction applies if you take medications on a regular basis. Take your usual medications at (approximately) the regularly scheduled times at least two hours before the appointment, with a few sips of water (and water only).</li> <li>Arrangements must be made to have a responsible adult take you home, by car or taxi (a taxi driver alone is not allowed to take you home). You may NOT go home by public transit.</li> <li>Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish.</li> <li>Contact us prior to the appointment if has there been a change in your general health (egs, severe cold, fever, etc.)</li> </ol> <p></p> <h5>INSTRUCTIONS FOLLOWING YOUR SEDATION/ANESTHESIA APPOINTMENT</h5> <p> </p><ol> <li>You may be drowsy for the remainder of the day and should be relaxing at home in the care of a responsible adult until you are fully alert.</li> <li>You must not drive a car or operate machinery for at least 18 hours, longer if drowsiness or dizziness persists.</li> <li>Replenish your energy by having something to eat or drink as soon as possible.</li> <li>Do not drink alcoholic beverages for a minimum of 18 hours after the procedure.</li> <li>Do not sign any important or legal documents for 24hrs.</li> <li>If there are any questions or concerns, contact the dental office. In case of an emergency, you should go to the nearest emergency room.</li> </ol> <p></p></div><fieldset id="field_15_63" class="gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Signature</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_container ginput_container_signature"><input type='hidden' value='' name='input_63' id='input_15_63_signature_filename' class='gfield_signature_filename' /><div class='gfield_signature_ui_container gform-theme__no-reset--children'><div id='input_15_63_Container' class='gfield_signature_container' style='height:90px;width:300px'><input type='hidden' id='input_15_63_data' name='input_15_63_data' class='gfield_signature_data' />
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226<span class="gfield_required gfield_required_asterisk">*</span>&quot; indicates required fields</p> </div><form method='post' enctype='multipart/form-data' id='gform_14' action='/locations/#gf_14' data-formid='14' novalidate> <div id='gf_progressbar_wrapper_14' class='gf_progressbar_wrapper' data-start-at-zero=''> <p class="gf_progressbar_title">Step <span class='gf_step_current_page'>1</span> of <span class='gf_step_page_count'>7</span><span class='gf_step_page_name'></span> </p> <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'> <div class='gf_progressbar_percentage percentbar_blue percentbar_14' style='width:14%'><span>14%</span></div> </div></div> <div class='gform-body gform_body'><div id='gform_page_14_1' class='gform_page ' data-js='page-field-id-0'> <div class='gform_page_fields'><div id='gform_fields_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_2" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH</h5> <h5>WHAT IS AN IMPACTED TOOTH?</h5> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <h5>WHAT HARM CAN IMPACTED TEETH DO?</h5> <p></p><ol><li>Impacted teeth may grow in any direction; however they often grow forward and push against the adjacent second molar. This can result in pain in the second molar and possibly damage to the roots or crown. The second molar may also be pushed out of position.</li> <li>All teeth develop in sacs deep in the bone. If the tooth erupts normally, the sac generally disappears. If the tooth is impacted, the sac can fill with fluid and enlarge to form a cyst. The cyst can cause destruction of surrounding bone and damage to other teeth in the area.</li> <li>Whenever saliva can reach the tooth, decay may occur, and since such cavities cannot be filled severe pain may result. This may be followed by the formation of an abscess.</li> <li>Bacteria in the saliva may cause an infection around the crown of the wisdom tooth and under the flap of gum tissue which may be covering part of the tooth. This infection may spread to the cheek, throat or neck and result in severe pain, stiffness of the jaws, fever, and severe generalized illness.</li> <li>Pressure from the wisdom teeth may cause crowding of the front teeth. This is why some orthodontists do not consider orthodontic treatment complete until impacted third molars have been removed.</li></ol><p></p> <h5>WHEN IS IT BEST TO HAVE WISDOM TEETH REMOVED?</h5> <p>The dentist can study x-rays of the teeth and jaws, and can frequently tell by the teen years if the wisdom teeth are going to be impacted. At this stage the roots are usually not fully formed in most people and the bone is less dense. Therefore, the wisdom teeth are less complicated to remove and the healing is generally faster.</p> <h5>WHAT IS IT LIKE TO HAVE AN IMPACTED TOOTH REMOVED?</h5> <p>Because the impacted tooth is usually completely beneath the surface of the gum and often encased in bone, we consider its removal an operation in every sense of the word. This is said not to frighten the prospective patient, but rather to give a better understanding about certain features regarding cost, careful preparations and the need for good aftercare. Either local and general anaesthesia or local and sedation may be used. The dentist chooses the method of treatment based on each individual situation. Having a comfortable patient helps to control bleeding, allows the dentist to work without haste and causes less physiological disturbance to the patient. The actual removal of the tooth is done in keeping with recognized surgical principles, with meticulously sterile instruments, good light, a dry operative field, gentle handling of the soft tissue and bone and the advantages of a well trained team. Depending on the degree of difficulty of the individual case, the procedure may last from fifteen to sixty minutes. If sedation or general anaesthesia is used there will be a recovery period from thirty to ninety minutes. The surgical wound may be sutured with a material of the dentist’s choice. Most often dissolving sutures are used.<
226/p> <h5>WHAT SHOULD I EXPECT AFTER SURGERY?</h5> <p>After any surgical procedure a certain amount of discomfort is anticipated. For this reason you will be provided with pain relieving medication before you leave the office. You are to take your pain medication as directed by the dentist; instructions will be on the bottle. Your dentist will decide if antibiotic medication is necessary and if this medication has been prescribed then it should be taken until all tablets are gone. Swelling after surgery is normal. You should expect to be most swollen forty eight to seventy two hours after surgery. The swelling then begins to resolve. Certain individuals have bruising after wisdom teeth surgery. The bruising may extend into the neck and chest. This should not alarm you as in some individuals this is the normal sequence of events.</p> <p>Stiffness of the jaws is also normal after wisdom teeth surgery and is usually at its worst two or three days after surgery. One should start to exercise the jaws on the second or third post operative day to return the jaws to normal.</p> <p>Although it will probably be difficult to eat after surgery in the mouth one must remember that the body heals itself by drawing upon its reserves of protein, vitamins, minerals, calcium and iron. Failure to replenish the body’s supplies of the above mentioned nutrients can result in fatigue, infections and even delayed healing. For the first twenty-four hours following surgery your food and beverages should be warm or cold NOT HOT. Eggs, custards, yogurt, milkshakes, baby food, etc., are both nutritious and manageable. Fluid intake should be approximately two litres or eight juice glasses per day for the average adult.</p> <p>Detailed post operative instructions will be provided before you leave the office.</p> <h5>ARE THERE ANY COMPLICATIONS OR RISKS?</h5> <p>Any operation carries some degree of risk. This risk is minimized by careful preoperative assessment of your physical condition, by careful examination of all of the diagnostic materials, by careful preparation of instruments and all facilities, and by the skill of your dental team. The most commonly encountered complications will be discussed below.</p> <p>Post-operative bleeding is usually encountered when the patient has not placed the gauze pack DIRECTLY over the surgical site. Pressure over the site for forty-five to sixty minutes will control most post-operative bleeding. If you are still concerned call the office and the problem will be dealt with promptly.</p> <p>A condition known as dry socket occurs in approximately five percent of patients. It is more common in smokers and in female patients on the pill. It is manifest by a dull throbbing pain which starts five or seven days after the operation and is accompanied by a foul odour from the mouth. The treatment for this problem is simple and consists of two or three dressing changes. Healing is slightly slower than normal.</p> <p>The roots of lower impacted teeth very often rest on and around the main nerve of the lower jaw. Very rarely, in spite of all precautions, during the removal of lower third molars this nerve is bruised, slightly lacerated or even severed. The result will be numbness of the lower lip, chin, and all of the teeth on that side. This effect does not last longer than a few weeks in most cases. It improves as the nerve repairs itself and regenerates. Occasionally the numbness may last as long as two or five years and even more rarely it may be permanent .Also in the region of the lower third molar is the nerve which supplies sensation to the lateral part of the tongue. It may on occasion be stretched with a resultant numb tongue. This problem usually resolves within several weeks or months. Upper impacted third molars lie against the wall of the sinus. Great care is taken to insure that no injury occurs to this structure but occasionally the thin wall of bone cracks and blood seeps into the sinus. Occasionally there may be formed a communication between the sinus and the mouth. If your dentist suspects this to be the case you will be informed and additional medication will be prescribed. Infections after the removal of wisdom teeth are rare. Redness, increasing swelling after an initial decrease, foul tasting discharge into the mouth, fever and chills are all signs if infection. If these should appear call the office and you will be attended to promptly.</p> <p>Occasionally large fillings in the second molar teeth may be loosened or cracked during the removal of the wisdom teeth in spite of immaculate care and skill. If the possibility of this exists prior to surgery, you will be informed.</p> <p>Another very rare complication is a cracked or fractured lower jaw. This occurs when the wisdom tooth is very severely impacted. If your dentist is concerned about this possibility, you will be informed.</p> <p>Dr. Brian Kumer<br /><a href="tel:4166050008">(416) 605-0008</a></p> </div><fieldset id="field_14_29" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_29'><div class='gchoice gchoice_14_29_1'> <input class='gfield-choice-input' name='input_29.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_29_1' /> <label for='choice_14_29_1' id='label_14_29_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_14_4' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_2' class='gform_page' data-js='page-field-id-4' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_5" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ORAL SURGERY CONSENT FORM</h5> <h5>SWELLING, BRUISING AND PAIN</h5> <p>These can occur with any surgery and vary between patients and from one surgery to another. You may require several days at home for recovery. You may also have stretching of the corners of the mouth that may cause bruising and may heal slowly.</p></div><fieldset id="field_14_30" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SWELLING, BRUISING AND PAIN</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_30'><div class='gchoice gchoice_14_30_1'> <input class='gfield-choice-input' name='input_30.1' type='checkbox' value='I have read and understand this section.' id='choice_14_30_1' /> <label for='choice_14_30_1' id='label_14_30_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_28" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TRISMUS</h5> <p>This is the limited opening of the jaws due to inflammation in the muscles. This is more common with impacted tooth removal but is possible with almost any surgery. There is a higher likelihood if TMJ (see below) problem already exists.</p></div><fieldset id="field_14_73" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TRISMUS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_73'><div class='gchoice gchoice_14_73_1'> <input class='gfield-choice-input' name='input_73.1' type='checkbox' value='I have read and understand this section.' id='choice_14_73_1' /> <label for='choice_14_73_1' id='label_14_73_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_72" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INFECTION</h5> <p>This is possible with any surgical procedure and may require further surgery and/or medications if it does occur.</p></div><fieldset id="field_14_74" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFECTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_74'><div class='gchoice gchoice_14_74_1'> <input class='gfield-choice-input' name='input_74.1' type='checkbox' value='I have read and understand this section.' id='choice_14_74_1' /> <label for='choice_14_74_1' id='label_14_74_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_71" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>BLEEDING</h5> <p>Although significant bleeding can occur during or after surgery, it is not common. Some bleeding is, however, expected with most surgeries and is normally controlled by following the post-op instruction sheet. Prolonged or heavy bleeding may require additional treatment.</p></div><fieldset id="field_14_75" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>BLEEDING</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_75'><div class='gchoice gchoice_14_75_1'> <input class='gfield-choice-input' name='input_75.1' type='checkbox' value='I have read and understand this section.' id='choice_14_75_1' /> <label for='choice_14_75_1' id='label_14_75_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_70" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TMJ DYSFUNCTION</h5> <p>This means the jaw joint (Tempromandibular Joint) may not function properly and, although rare, may require treatment ranging from use of hot/cold compress and rest to further surgery.</p></div><fieldset id="field_14_76" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TMJ DYSFUNCTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_76'><div class='gchoice gchoice_14_76_1'> <input class='gfield-choice-input' name='input_76.1' type='checkbox' value='I have read and understand this section.' id='choice_14_76_1' /> <label for='choice_14_76_1' id='label_14_76_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_68" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>LOCAL ANAESTHESIA</h5> <p>Certain possible risks exist that, although uncommon or rare, could include pain, swelling, bruising, infection, nerve damage, idiosyncratic or allergic reactions.</p></div><fieldset id="field_14_77" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>LOCAL ANAESTHESIA</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_77'><div class='gchoice gchoice_14_77_1'> <input class='gfield-choice-input' name='input_77.1' type='checkbox' value='I have read and understand this section.' id='choice_14_77_1' /> <label for='choice_14_77_1' id='label_14_77_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_69" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ALLERGIC REACTION</h5> <p>Allergic reaction, such as itching, rash, swelling, difficulty in breathing, is possible to any medication used it treatment.</p></div><fieldset id="field_14_78" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>ALLERGIC REACTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_78'><div class='gchoice gchoice_14_78_1'> <input class='gfield-choice-input' name='input_78.1' type='checkbox' value='I have read and understand this section.' id='choice_14_78_1' /> <label for='choice_14_78_1' id='label_14_78_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_67" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DRY SOCKET</h5> <p>This is significant pain in the jaw and ear due to the loss of the blood clot and most commonly occurs after the removal of lower wisdom teeth, but it is possible with any extractions. Incidence increases with poor oral hygiene, smoking, birth control pill use. This may require additional office visits to treat.</p></div><fieldset id="field_14_79" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DRY SOCKET</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_79'><div class='gchoice gchoice_14_79_1'> <input class='gfield-choice-input' name='input_79.1' type='checkbox' value='I have read and understand this section.' id='choice_14_79_1' /> <label for='choice_14_79_1' id='label_14_79_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_65" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DAMAGE TO OTHER TEETH AND FILLINGS</h5> <p>Due to the close proximity of teeth, it is possible to damage other teeth and/or fillings when a tooth is removed</p></div><fieldset id="field_14_80" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DAMAGE TO OTHER TEETH AND FILLINGS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_80'><div class='gchoice gchoice_14_80_1'> <input class='gfield-choice-input' name='input_80.1' type='checkbox' value='I have read and understand this section.' id='choice_14_80_1' /> <label for='choice_14_80_1' id='label_14_80_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_64" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SHARP RIDGES AND BONE SPLINTERS</h5> <p>Occasionally, after an extraction, the edge of the socket will be sharp or a bone splinter will come out through the gum. This may require another surgery to smooth or remove the bone splinter.</p></div><fieldset id="field_14_85" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SHARP RIDGES AND BONE SPLINTERS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_85'><div class='gchoice gchoice_14_85_1'> <input class='gfield-choice-input' name='input_85.1' type='checkbox' value='I have read and understand this section.' id='choice_14_85_1' /> <label for='choice_14_85_1' id='label_14_85_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_66" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</h5> <p>There are times when the dentist may decide to leave in a fragment or root of a tooth in order to avoid doing damage to adjacent structures such as nerves, sinuses, etc. or if an extensive risk of other complications is present with its removal.</p></div><fieldset id="field_14_82" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_82'><div class='gchoice gchoice_14_82_1'> <input class='gfield-choice-input' name='input_82.1' type='checkbox' value='I have read and understand this section.' id='choice_14_82_1' /> <label for='choice_14_82_1' id='label_14_82_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_63" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>NUMBNESS</h5> <p>Due to the proximity of roots to the nerve (especially wisdom teeth), it is possible to bruise or damage the nerve with removal of a tooth. This could remain for days, weeks, or very rarely, permanently. The lip, chin, cheek, gums and/or tongue could feel numb, tingling or have burning sensation.</p></div><fieldset id="field_14_83" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>NUMBNESS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_83'><div class='gchoice gchoice_14_83_1'> <input class='gfield-choice-input' name='input_83.1' type='checkbox' value='I have read and understand this section.' id='choice_14_83_1' /> <label for='choice_14_83_1' id='label_14_83_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_62" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SINUS INVOLVEMENT</h5> <p>Due to the location of the roots (especially the upper back teeth) to the sinus, it is possible for an opening to develop from the sinus to the mouth. Or a tooth/fragment may be displaced into the sinus. A possible infection and/or permanent opening from the mouth into the sinus could develop and may require medication and/ or later surgery.</p></div><fieldset id="field_14_84" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SINUS INVOLVEMENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_84'><div class='gchoice gchoice_14_84_1'> <input class='gfield-choice-input' name='input_84.1' type='checkbox' value='I have read and understand this section.' id='choice_14_84_1' /> <label for='choice_14_84_1' id='label_14_84_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_61" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>JAW FRACTURE</h5> <p>Fracture of the jaw, usually in more complicated extractions.</p></div><fieldset id="field_14_81" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>JAW FRACTURE</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_81'><div class='gchoice gchoice_14_81_1'> <input class='gfield-choice-input' name='input_81.1' type='checkbox' value='I have read and understand this section.' id='choice_14_81_1' /> <label for='choice_14_81_1' id='label_14_81_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_14_60" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>QUALIFICATION</h5> <p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions, including wisdom teeth and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p></div><fieldset id="field_14_59" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>QUALIFICATION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_59'><div class='gchoice gchoice_14_59_1'> <input class='gfield-choice-input' name='input_59.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_59_1' /> <label for='choice_14_59_1' id='label_14_59_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_14_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_14_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_3' class='gform_page' data-js='page-field-id-7' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_9" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h3></div><div id="field_14_52" class="gfield gfield--type-html gfield--in
226put-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_14_54" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_14_55" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_55'><div class='gchoice gchoice_14_55_1'> <input class='gfield-choice-input' name='input_55.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_55_1' /> <label for='choice_14_55_1' id='label_14_55_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_14_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_14_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_4' class='gform_page' data-js='page-field-id-15' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_16" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p><b>Ontario’s Narcotics Strategy</b></p> <p><b>List Of Approved Forms Of Identification</b></p> <p> </p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul><p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li>Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Canadian Immigration Identification Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>Royal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_14_32" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_32'><div class='gchoice gchoice_14_32_1'> <input class='gfield-choice-input' name='input_32.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_32_1' /> <label for='choice_14_32_1' id='label_14_32_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_14_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_14_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_5' class='gform_page' data-js='page-field-id-18' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_19" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST-OPERATIVE INSTRUCTIONS</h5> <p style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></p> <p style="text-align:center">PLEASE READ THESE INSTRUCTIONS CAREFULLY. Sometimes the after effects of oral surgery are quite minimal, so not all of these instructions may apply to you. Common sense will dictate what you should do. However, when in doubt, follow these guidelines or call us for advice.</p> <p style="text-align:center">DAY OF SURGERY (FIRST 24 HRS)</p> <p style="text-align:center">AND DAYS 2-7</p> <h5>FIRST HOUR</h5> <p>Bite down gently but firmly on the gauze packs that have been placed on the surgical sites, making sure they remain in place. Do not change them for the first 30 minutes unless the bleeding is not being controlled. If active bleeding persists after 30 minutes, place enough new gauze to obtain pressure over the surgical site for another 30 minutes. The gauze may be changed as necessary and may be dampened for more comfortable positioning. Do not disturb the surgical area today.NO RINSING, WHATSOEVER, DURING THIS PHASE. DO NOT SMOKE. Smoking increases the risk of dry socket dramatically.</p> <h5>OOZING/BLEEDING</h5> <p>It’s normal to have your saliva stained with blood for a few days. There may also be some slight oozing. If this persists, place fresh gauze over the area and bite down for 30-60 minutes. Bleeding should never be severe. If it is, it usually means the gauze packs are placed between your teeth and not over the surgical sites. Try to reposition them. If this doesn’t work substitute a moistened tea bag wrapped in moist gauze for 30-60 minutes. Do not sleep with gauze in your mouth.When sleeping use an old pillow and place some towels around your head to protect your bedding. If bleeding remains uncontrolled please call us.</p> <h5>SWELLING</h5> <p>Often there is swelling/bruising associated with oral surgery. Swelling is a normal response to trauma. It is not the same as infection. If you are swollen this does not mean you are infected. You can minimize this by using an ice pack applied to the face adjacent to the surgical site. The ice should be applied for a 10 minutes per side every hour over a 24-48 hour period. After the first 24-48 hours, stop icing the area. Do not use ice packs while sleeping. Despite icing the area, swelling will still occur. After 48 hours, apply a warm moist compress for 10-15 min of several times a day for balance of the week. Swelling usually increases over a 72 hour period. Therefore you will appear more swollen on the 3rd day than the 2nd day. After 72 hours, swelling starts to slowly subside and is mostly gone by the 7th day.</p> <h5>RINSING</h5> <p>After the first 48 hours have elapsed you may stop icing the area. At this time start with warm salt water rinse. Place a teaspoon of salt in a glass of warm water. Gently swish it around your mouth 2-3 times a day for the next 7-10 days. Do not spit out the rinse. Let it fall out of your mouth. Spitting exerts a force on the healing clot and can slow down healing and promote bleeding. Do not use mouthwash for the first 7 days unless prescribed by the dentist. Also you may brush in the area unaffected by the surgery butleave the surgical areas alone for 7 days. After that you may gently clean around the area although swelling and soreness may not permit you to do so. In time, you will be able to return to proper oral hygiene care.</p> <h5>PAIN</h5> <p>Unfortunately oral surgery is usually accompanied by some degree of discomfort. You may have been given some pain medication prior to the start of your procedure. It is important to follow the instructions with pain medication as it is easier to “stay ahead of the pain rather than trying to catch up to it.” If you take the first pain pill before the local anesthetic has worn off you will be able to manage the discomfort better.</p> <h5>INFECTION</h5> <p>Unless you present with infection you usually don’t develop an infection in the first few days. Antibiotics are prescribed to either help prevent infections from developing or to treat an infection that is present. Not all procedures require an antibiotic. There is a decrease in effectiveness of birth control medication when taking antibiotics. 
226Consult your physician for advice on additional birth control measures. Slightly elevated temperature may occur for reasons other than infection. Be sure to drink lots of fluids: 1.5-2 liters /day.</p> <h5>DIET</h5> <p>Soft food is the dietary choice for the first few days. Ice cream, Jell-O, pudding, mashed potatoes, soups, pasta, or baby food are good choices. Avoid foods like nuts, popcorn, and rice as they tend to get stuck in the socket areas. Drinks like ENSURE or BOOST are good supplements as well. <b>DO NOT USE A STRAW OR DRINK FROM A BOTTLE</b> for the first 2-3 days. This can exert a force on the blood clot and slow down healing and promote bleeding. Use a spoon or a cup. After the fourth day you can progress to solid foods at you own pace. It is important to eat as you will feel better and heal faster. If you are diabetic, maintain you normal eating habits as much as possible and consult your physician regarding your insulin schedule.</p> <h5>STITCHES</h5> <p>You may have had some stitches placed. They will dissolve on their own in 5-7 days.Not all surgical sites require stitches.If a stitch comes out it is of no concern provided there is no excessive bleeding.</p> <h5>SMOKING</h5> <p>Do not smoke!It is advisable not to smoke for at least 7days.</p> <h5>SYRINGE</h5> <p>You will be given an irrigating syringe at your appointment. Fill a cup with salt water and then fill the syringe. Gently place it in the LOWER SOCKET ONLY and irrigate it 2-3 times. Do this after each meal over the next three to four weeks until the sockets close up. <b>DO NOT USE THE SYRINGE UNTIL 5 DAYS AFTER YOUR SURGERY!</b></p> <h5>REST</h5> <p>You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved.</p> <p>You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved.</p> <p>SHOULD YOU BE UNABLE TO REACH ME IN AN EMERGENCY, GO TO THE NEAREST EMERGENCY ROOM</p> <p style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></p></div><fieldset id="field_14_33" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST-OPERATIVE INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_33'><div class='gchoice gchoice_14_33_1'> <input class='gfield-choice-input' name='input_33.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_33_1' /> <label for='choice_14_33_1' id='label_14_33_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_14_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_14_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_6' class='gform_page' data-js='page-field-id-21' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_22" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IV General Anesthesia consent form</h5> <p>I authorize Dr. Stephen Ing and associates/assistants of his choice to perform intravenous sedation/anesthesia, as a part of my dental procedure. Additionally, I authorize the performance of any other procedure that in the judgment of Dr. Ing may be necessary for my well-being, including such interventions that are considered medically advisable to remedy conditions encountered during the proposed procedure.</p> <p>I am satisfied with my understanding of the nature of the anesthesia plan of care and the more common drawbacks and complications associated with it. These may include, but are not limited to: swelling, bleeding or discomfort at the site of intravenous insertion; allergic reactions to the anesthetic agents used; nausea and/or vomiting; prolonged recovery from anesthesia; post-operative disorientation/delirium (temporary); aspiration of stomach contents (rare); sore throat; fractured teeth; sore/bleeding nose. There is also a very rare potential for serious harm, including respiratory and cardiac arrest which can result in brain damage or death. I understand the risks, complications, and potential benefits of anesthesia. I have been given ample opportunity to discu
226ss alternative methods of treatment, if any, along with their risks and benefits. No warranty or guarantee has been made as to the outcome of the anesthesia plan of care.</p> <p>I understand that in some instances where a general anesthetic (ie, completely asleep/unconscious) has been specifically requested, Dr. Ing may use a breathing tube to ensure that the patient's airway remains unobstructed during the procedure. In these instances, there is an increased chance of a temporary sore throat or in much rarer circumstances, physical trauma to the airway.</p> <p>I understand that anesthetics and other medicines may be harmful to an unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing Dr. Ing of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation/anesthetic. For similar reasons, I understand that I must inform Dr. Ing if I am a nursing mother.</p> <p>I understand and agree to the following post-anesthetic instructions: </p><ol> <li>I will not drive a car or operate machinery for at least 24 hours, longer if drowsiness or dizziness persists.</li> <li>I will not drink alcoholic beverages for a minimum of 24 hours after the procedure.</li> <li>I will be in the care of a responsible adult until I am fully alert.</li> </ol> <p></p></div><fieldset id="field_14_34" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>IV General Anesthesia consent form</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_14_34'><div class='gchoice gchoice_14_34_1'> <input class='gfield-choice-input' name='input_34.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_14_34_1' /> <label for='choice_14_34_1' id='label_14_34_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_14_24' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_14_24' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_14_7' class='gform_page' data-js='page-field-id-24' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_14_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_14_25" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>Pre And Post-anesthesia Instructions</h5> <h5>PRE-OPERATIVE INSTRUCTIONS FOR PATIENTS WHO WILL BE RECEIVING SEDATION OR ANESTHESIA></h5> <p> </p><ol> <li>Nothing to eat or drink (including water) for 8 hours before the procedure.</li> <li>The only exception to the above instruction applies if you take medications on a regular basis. Take your usual medications at (approximately) the regularly scheduled times at least two hours before the appointment, with a few sips of water (and water only).</li> <li>Arrangements must be made to have a responsible adult take you home, by car or taxi (a taxi driver alone is not allowed to take you home). You may NOT go home by public transit.</li> <li>Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish.</li> <li>Contact us prior to the appointment if has there been a change in your general health (egs, severe cold, fever, etc.)</li> </ol> <p></p> <h5>INSTRUCTIONS FOLLOWING YOUR SEDATION/ANESTHESIA APPOINTMENT</h5> <p> </p><ol> <li>You may be drowsy for the remainder of the day and should be relaxing at home in the care of a responsible adult until you are fully alert.</li> <li>You must not drive a car or operate machinery for at least 18 hours, longer if drowsiness or dizziness persists.</li> <li>Replenish your energy by having something to eat or drink as soon as possible.</li> <li>Do not drink alcoholic beverages for a minimum of 18 hours after the procedure.</li> <li>Do not sign any important or legal documents for 24hrs.</li> <li>If there are any questions or concerns, contact the dental office. 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top&quot;,&quot;position_from_trigger&quot;:false,&quot;position_top&quot;:&quot;100&quot;,&quot;position_left&quot;:&quot;0&quot;,&quot;position_bottom&quot;:&quot;0&quot;,&quot;position_right&quot;:&quot;0&quot;,&quot;position_fixed&quot;:false,&quot;animation_type&quot;:&quot;fade&quot;,&quot;animation_speed&quot;:&quot;350&quot;,&quot;animation_origin&quot;:&quot;center top&quot;,&quot;overlay_zindex&quot;:false,&quot;zindex&quot;:&quot;1999999999&quot;},&quot;close&quot;:{&quot;text&quot;:&quot;&quot;,&quot;button_delay&quot;:&quot;0&quot;,&quot;overlay_click&quot;:false,&quot;esc_press&quot;:false,&quot;f4_press&quot;:false},&quot;click_open&quot;:[]}}"> <div id="popmake-540" class="pum-container popmake theme-528 pum-responsive pum-responsive-small responsive size-small"> <div class="pum-content popmake-content" tabindex="0"> <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' 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226<span class="gfield_required gfield_required_asterisk">*</span>&quot; indicates required fields</p> </div><form method='post' enctype='multipart/form-data' id='gform_17' action='/locations/#gf_17' data-formid='17' novalidate> <div id='gf_progressbar_wrapper_17' class='gf_progressbar_wrapper' data-start-at-zero=''> <p class="gf_progressbar_title">Step <span class='gf_step_current_page'>1</span> of <span class='gf_step_page_count'>8</span><span class='gf_step_page_name'></span> </p> <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'> <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%'><span>12%</span></div> </div></div> <div class='gform-body gform_body'><div id='gform_page_17_1' class='gform_page ' data-js='page-field-id-0'> <div class='gform_page_fields'><div id='gform_fields_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_2" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IMPLANT SURGERY</h5> <h5>INFORMATION AND CONSENT FORM</h5> <p></p><ol> <li>I have been informed of and I understand the purpose and nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.</li> <li>My doctor has carefully examined my mouth and explained alternatives to this treatment have been explained to me. I have either tried or have considered these options and have concluded that an implant is my treatment of choice to secure the tooth or denture to be replaced.</li> <li>I have further been informed of the possible risks and complications involved with surgery, drugs (allergic or adverse reactions) and anesthesia. Such complications include pain, swelling, infection, bruising. Numbness of the lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Other possible risks are injury to other teeth, bone fractures, sinus perforation, delayed healing, rejection of the implant.</li> <li>It has been explained to me that in some instances implants fail and must be removed. The success rate of dental implant surgery is very high but dentistry is not an exact science and no guarantee or assurance as to the outcome of the result of treatment can be made.</li> <li>I understand that if nothing is done any of the following could occur: loss of bone and/or gum tissue, inflammation of the gums, infection, loose teeth, loss of teeth, and the occurrence or reoccurrence of Temporomandibular (jaw) joint symptoms</li> <li>I understand that excessive smoking, alcohol, or sugar may affect healing and may limit the success of the implant. I agree to follow my doctors home care instructions. I agree to report to my doctor for regular examinations as instructed.</li> <li> To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, reported any bleeding disorders or any other condition related to my health</li> <li>I consent to the photographing filming videotaping of the procedure to be performed provided my identity is not revealed.</li> <li>I request and authorize the dental services for me, including implants and other surgical procedures as deemed necessary to accomplish the placement of the implants. I fully understand that during and following the procedure conditions may become apparent that warrant additional or alternative treatments pertinent o the success of the comprehensive treatment. I also approve any modification in the design or materials if it is felt to be in my best interest.</li> <li>The fees for this treatment plan and the payment plan have been explained to me and I have approved them.</li></ol><p></p></div><fieldset id="field_17_144" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFORMATION AND CONSENT FORM</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_144'><div class='gchoice gchoice_17_144_1'> <input class='gfield-choice-input' name='input_144.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_144_1' /> <label for='choice_17_144_1' id='label_17_144_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_17_199' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_2' class='gform_page' data-js='page-field-id-199' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_9" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h5> </div><div id="field_17_169" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_17_141" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_17_170" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_170'><div class='gchoice gchoice_17_170_1'> <input class='gfield-choice-input' name='input_170.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_170_1' /> <label for='choice_17_170_1' id='label_17_170_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_135' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_135' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_3' class='gform_page' data-js='page-field-id-135' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_16" class="gfield gfield--type-html gfield--in
226put-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p><b>Ontario’s Narcotics Strategy</b></p> <p><b>List Of Approved Forms Of Identification</b></p> <p> </p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul><p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li>Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Canadian Immigration Identification Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>Royal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_17_147" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_147'><div class='gchoice gchoice_17_147_1'> <input class='gfield-choice-input' name='input_147.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_147_1' /> <label for='choice_17_147_1' id='label_17_147_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_136' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_136' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_4' class='gform_page' data-js='page-field-id-136' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_19" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST OP FOR DENTAL IMPLANTS</h5> <p></p><ol> <li><b>Smoking:</b> Do not smoke. Patients who smoke will experience delayed healing and greater discomfort and are at higher risk for infection. In addition smoking will compromise your result.</li> <li><b>Medication:</b> It is important to follow the instructions written on your prescription. If you experience any unfavourable reactions such as nausea, vomiting, diarrhea, rash, etc. call the doctor.</li> <li><b>Rest:</b> Do not plan on any activities for the remainder of the day. Avoid any strenuous activity for 1 week following surgery.</li> <li><b>Pain:</b> Some discomfort is expected once the anesthetic wears off. If you were prescribed post-operative pain medication, begin taking it before the anesthetic wears off to minimize discomfort. Ibuprofen is an effective pain medication and also reduces swelling. It can be taken for the first 3-4 days on a continuous basis (4 times per day) with a maximum dose of 3 grams per day. You may take Ibuprofen in addition to and at the same time as a prescribed narcotic such as Tylenol #2 or #3.</li> <li><b>Swelling:</b> Some swelling may occur the day after surgery and will generally persist for 24-36 hours, then diminish.Swelling can be minimized by placing an ice pack on the outside of the face over the surgical site alternating on and off in 10 minute intervals. You should do this forthe 24 hours following your surgery.</li> <li><b>Bleeding:</b> There should be no outright bleeding after surgery, though a slight pinkish colour to your saliva is common. If bleeding occurs, place a moistened non herbal tea bag over the area and apply gentle pressure. Continue this for 20 minutes. If bleeding persists call the doctor.</li> <li> <b>Rinsing:</b> Following your surgery you should rinse with warm salt water for the next 24 hours. Do not brush or floss or water pik in the area involved in the surgery. If you have been prescribed mouthwash use it twice daily until the stiches are removed. Make sure there is no toothpaste in your mouth when rinsing.</li> <li><b>Diet:</b> It is important to maintain a normal healthy diet. Do not drink any hot drinks for the first 24 hours. The 4 days following surgery eat soft foods (oatmeal, cottage cheese, eggs, avocado, fruit and vegetable juices) Try to do 
226your chewing on the opposite site of your mouth from where the surgery took place. Avoid any coarse foods such as seeds, nuts, chips, popcorn etc. . . . It may be necessary to maintain a liquid diet for a few days. Increase your fluid intake during this time. Avoid using a straw for 4 days.</li> </ol><p></p> <h5 style="text-align:center">Dr. Brian Kumer<br /><a href="tel:+4166050008">(416) 605-0008</a></h5></div><fieldset id="field_17_146" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST OP FOR DENTAL IMPLANTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_146'><div class='gchoice gchoice_17_146_1'> <input class='gfield-choice-input' name='input_146.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_146_1' /> <label for='choice_17_146_1' id='label_17_146_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_137' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_137' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_5' class='gform_page' data-js='page-field-id-137' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_22" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>PRE-SEDATION INSTRUCTIONS</h5> <h5>IF YOU DO NOT FOLLOW THE IV SEDATION INSTRUCTIONS, YOUR APPOINTMENT WILL BE <b>CANCELLED</b></h5> <p> </p><ol> <li>A: Do not eat or drink anything (EXCEPT WATER) for at least 8 hours prior to your appointment.</li> <p>B: You may drink water <strong>(ONLY)</strong>, at least 3 hours before the appointment.</p> <li><strong>IF YOU ARE A PATIENT WITH DIABETES (TYPE I OR TYPE II).</strong> Please consult your physician regarding your diabetes medication management prior to your dental appointment.</li> <li>If you need to take medications prescribed by your physician, TAKE IT WITH SIPS OF WATER ONLY, AT LEAST 3 HOURS prior to your appointment.</li> <li>You must have a responsible ADULT (relative or friend) escort you home in a car or taxi. You may not take public transit home!</li> <li>Please wear <strong>loose comfortable clothing preferably short sleeved (eg, t-shirt). </strong> Do not wear facial makeup or nail polish (at least one finger).</li> <li>Do not drink grapefruit juice for at least 24 hours prior to surgery.</li> </ol> <p></p> <p> Contact us prior to your appointment if there has been a change to your general health.</p> <p>IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL</p> <p>DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></p></div><fieldset id="field_17_148" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>PRE-SEDATION INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_148'><div class='gchoice gchoice_17_148_1'> <input class='gfield-choice-input' name='input_148.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_148_1' /> <label for='choice_17_148_1' id='label_17_148_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_138' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_138' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_6' class='gform_page' data-js='page-field-id-138' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_25" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST SEDATION INSTRUCTIONS</h5> <p> </p><ol> <li>Do not drive or operate hazardous equipment for 24hrs after sedation.</li> <li>A responsible person should remain with the patient for 24 hours.</li> <li>Patients must not go up or down stairs unescorted for 24hrs.</li> <li>No unattended bath or shower for 24 hrs.</li> <li>Diet is restricted by surgical procedure not the sedation.</li> <li>Drink plenty of fluids, 1.5-2 litres per day in the first three to four days.</li> <li>Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner.</li> <li>Don’t use any pillows for the first night.</li> <li>No alcohol or any other drugs with sedative properties for 24 hours or longer if drowsiness persists.</li> <li>Do not sign any important or legal documents for 24hrs.</li> <li>Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately.</li> </ol> <p></p> <p>Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killer
226s are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist.</p> <p style="text-align:center"><b>DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></b></p></div><fieldset id="field_17_149" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST SEDATION INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_149'><div class='gchoice gchoice_17_149_1'> <input class='gfield-choice-input' name='input_149.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_149_1' /> <label for='choice_17_149_1' id='label_17_149_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_139' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_139' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_7' class='gform_page' data-js='page-field-id-139' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_28" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IVCS Consent</h5> <p style="text-align:center">Dr. Brian Kumer DDS<br />Consent for I.V. Conscious Sedation</p> <p>This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation.</p> <p>The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year.</p> <p>I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent.</p> <p> I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother.</p> <p>Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation.</p> <p>I have been advised of and completely understand the risks, benef
226its, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer.</p> <p> I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees.</p> <p><b>I certify that I fully understand the terms within the above consent.</b></p> </div><fieldset id="field_17_150" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>IVCS Consent</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_17_150'><div class='gchoice gchoice_17_150_1'> <input class='gfield-choice-input' name='input_150.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_17_150_1' /> <label for='choice_17_150_1' id='label_17_150_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_17_36' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_17_36' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_17_8' class='gform_page' data-js='page-field-id-36' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_17_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_17_171" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3>Pre-Anaesthesia Questionnaire </h3></div><div id="field_17_142" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_142'><span class='gform-field-label__text'>Patient ID *first 3 letters of your first name and the first 3 letters of your last name.:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_17_142' type='text' value='' class='large' placeholder='aaaaaa' aria-required="true" aria-invalid="false" data-mask="aaaaaa" /></div></div><div id="field_17_37" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_37'><span class='gform-field-label__text'>Date (Please add today&#039;s date)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_17_37' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_37' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_17_37' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_17_37' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_17_37' aria-label='Date (Please add today' s date): choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_17_39" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datedropdown gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Date of birth:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div id='input_17_39' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_17_39_1_container'><label for='input_17_39_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month</label><select name='input_39[]' id='input_17_39_1' aria-required='true'><option value=''>Month</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option></select></div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_17_39_2_container'><label for='input_17_39_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day</label><select name='input_39[]' id='input_17_39_2' aria-required='true' class="nitro-lazy"><option value=''>Day</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option><option value='13'>13</option><option value='14'>14</option><option value='15'>15</option><option value='16'>16</option><option value='17'>17</option><option value='18'>18</option><option value='19'>19</option><option value='20'>20</option><option value='21'>21</option><option value='22'>22</option><option value='23'>23</option><option value='24'>24</option><option value='25'>25</option><option value='26'>26</option><option value='27'>27</option><option value='28'>28</option><option value='29'>29</option><option value='30'>30</option><option value='31'>31</option></select></div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_17_39_3_container'><label for='input_17_39_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year</label><select name='input_39[]' id='input_17_39_3' aria-required='true'><option value=''>Year</option><option value='2027'>2027</option><option value='2026'>2026</option><option value='2025'>2025</option><option value='2024'>2024</option><option value='2023'>2023</option><option value='2022'>2022</option><option value='2021'>2021</option><option value='2020'>2020</option><option value='2019'>2019</option><option value='2018'>2018</option><option value='2017'>2017</option><option value='2016'>2016</option><option value='2015'>2015</option><option value='2014'>2014</option><option value='2013'>2013</option><option value='2012'>2012</option><option value='2011'>2011</option><option value='2010'>2010</option><option value='2009'>2009</option><option value='2008'>2008</option><option value='2007'>2007</option><option value='2006'>2006</option><option value='2005'>2005</option><option value='2004'>2004</option><option value='2003'>2003</option><option value='2002'>2002</option><option value='2001'>2001</option><option value='2000'>2000</option><option value='1999'>1999</option><option value='1998'>1998</option><option value='1997'>1997</option><option value='1996'>1996</option><option value='1995'>1995</option><option value='1994'>1994</option><option value='1993'>1993</option><option value='1992'>1992</option><option value='1991'>1991</option><option value='1990'>1990</option><option value='1989'>1989</option><option value='1988'>1988</option><option value='1987'>1987</option><option value='1986'>1986</option><option value='1985'>1985</option><option value='1984'>1984</option><option value='1983'>1983</option><option value='1982'>1982</option><option value='1981'>1981</option><option value='1980'>1980</option><option value='1979'>1979</option><option value='1978'>1978</option><option value='1977'>1977</option><option value='1976'>1976</option><option value='1975'>1975</option><option value='1974'>1974</option><option value='1973'>1973</option><option value='1972'>1972</option><option value='1971'>1971</option><option value='1970'>1970</option><option value='1969'>1969</option><option value='1968'>1968</option><option value='1967'>1967</option><option value='1966'>1966</option><option value='1965'>1965</option><option value='1964'>1964</option><option value='1963'>1963</option><option value='1962'>1962</option><option value='1961'>1961</option><option value='1960'>1960</option><option value='1959'>1959</option><option value='1958'>1958</option><option value='1957'>1957</option><option value='1956'>1956</option><option value='1955'>1955</option><option value='1954'>1954</option><option value='1953'>1953</option><option value='1952'>1952</option><option value='1951'>1951</option><option value='1950'>1950</option><option value='1949'>1949</option><option value='1948'>1948</option><option value='1947'>1947</option><option value='1946'>1946</option><option value='1945'>1945</option><option value='1944'>1944</option><option value='1943'>1943</option><option value='1942'>1942</option><option value='1941'>1941</option><option value='1940'>1940</option><option value='1939'>1939</option><option value='1938'>1938</option><option value='1937'>1937</option><option value='1936'>1936</option><option value='1935'>1935</option><option value='1934'>1934</option><option value='1933'>1933</option><option value='1932'>1932</option><option value='1931'>1931</option><option value='1930'>1930</option><option value='1929'>1929</option><option value='1928'>1928</option><option value='1927'>1927</option><option value='1926'>1926</option><option value='1925'>1925</option><option value='1924'>1924</option><option value='1923'>1923</option><option value='1922'>1922</option><option value='1921'>1921</option><option value='1920'>1920</option></select></div></div></fieldset>
226<div id="field_17_40" class="gfield gfield--type-select gfield--input-type-select gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_40'><span class='gform-field-label__text'>Sex:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_17_40' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Male'>Male</option><option value='Female'>Female</option><option value='Other'>Other</option></select></div></div><fieldset id="field_17_73" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>1. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_73'> <div class='gchoice gchoice_17_73_0'> <input class='gfield-choice-input' name='input_73' type='radio' value='Yes' id='choice_17_73_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_73_0' id='label_17_73_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_73_1'> <input class='gfield-choice-input' name='input_73' type='radio' value='No' id='choice_17_73_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_73_1' id='label_17_73_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_73_2'> <input class='gfield-choice-input' name='input_73' type='radio' value='Not Sure' id='choice_17_73_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_73_2' id='label_17_73_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_41" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>2. Do you have any health problems or concerns presently?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_41'> <div class='gchoice gchoice_17_41_0'> <input class='gfield-choice-input' name='input_41' type='radio' value='Yes' id='choice_17_41_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_41_0' id='label_17_41_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_41_1'> <input class='gfield-choice-input' name='input_41' type='radio' value='No' id='choice_17_41_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_41_1' id='label_17_41_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_41_2'> <input class='gfield-choice-input' name='input_41' type='radio' value='Not Sure' id='choice_17_41_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_41_2' id='label_17_41_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_42" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_42'><span class='gform-field-label__text'>Please explain</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_17_42' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_17_43" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>3. Has there been ANY change in your general health in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_43'> <div class='gchoice gchoice_17_43_0'> <input class='gfield-choice-input' name='input_43' type='radio' value='Yes' id='choice_17_43_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_43_0' id='label_17_43_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_43_1'> <input class='gfield-choice-input' name='input_43' type='radio' value='No' id='choice_17_43_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_43_1' id='label_17_43_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_43_2'> <input class='gfield-choice-input' name='input_43' type='radio' value='Not Sure' id='choice_17_43_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_43_2' id='label_17_43_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_45" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_45'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_17_45' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_46" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_46'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_17_46' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_201" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_201'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_17_201' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_203" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_203'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_17_203' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_204" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_204'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_17_204' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_205" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_205'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_17_205' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_47" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>4. Have you ever been in hospital for treatment?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_47'> <div class='gchoice gchoice_17_47_0'> <input class='gfield-choice-input' name='input_47' type='radio' value='Yes' id='choice_17_47_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_47_0' id='label_17_47_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_47_1'> <input class='gfield-choice-input' name='input_47' type='radio' value='No' id='choice_17_47_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_47_1' id='label_17_47_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_17_48" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_48'><span class='gform-field-label__text'>When, where and why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_17_48' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_49" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>5. Have you ever had IV Conscious Sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_49'> <div class='gchoice gchoice_17_49_0'> <input class='gfield-choice-input' name='input_49' type='radio' value='Yes' id='choice_17_49_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_49_0' id='label_17_49_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_49_1'> <input class='gfield-choice-input' name='input_49' type='radio' value='No' id='choice_17_49_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_49_1' id='label_17_49_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_49_2'> <input class='gfield-choice-input' name='input_49' type='radio' value='Not Sure' id='choice_17_49_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_49_2' id='label_17_49_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_50" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_50'><span class='gform-field-label__text'>When, where and why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_17_50' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_51" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_51'><span class='gform-field-label__text'>Were there any problems with the Sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_17_51' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_52" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>6. Has there been any personal or family history of issues with anesthesia, IV Conscious sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_52'> <div class='gchoice gchoice_17_52_0'> <input class='gfield-choice-input' name='input_52' type='radio' value='Yes' id='choice_17_52_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_52_0' id='label_17_52_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_52_1'> <input class='gfield-choice-input' name='input_52' type='radio' value='No' id='choice_17_52_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_52_1' id='label_17_52_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_52_2'> <input class='gfield-choice-input' name='input_52' type='radio' value='Not Sure' id='choice_17_52_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_52_2' id='label_17_52_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_53" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_53'><span class='gform-field-label__text'>Please explain</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_17_53' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_17_54" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_54'><span class='gform-field-label__text'>Were any tests done?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_17_54' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_180" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>7. Do you take ANY <strong>PRESCRIPTION</strong> medications (including puffers and birth control pills)? Do you use more than one pharmacy? If yes, provide Pharmacy name + phone number of <strong>ALL</strong> pharmacies you use.</p></div><fieldset id="field_17_173" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>7. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_173'> <div class='gchoice gchoice_17_173_0'> <input class='gfield-choice-input' name='input_173' type='radio' value='Yes' id='choice_17_173_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_173_0' id='label_17_173_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_173_1'> <input class='gfield-choice-input' name='input_173' type='radio' value='No' id='choice_17_173_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_173_1' id='label_17_173_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_17_182" class="gfield gfield--type-list gfield--input-type-list gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Name of Pharmacy &amp; Phone Number:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class="gfield_list_groups"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_182_cell1 gform-grid-col'><input aria-invalid='false' aria-required="true" aria-label='Name of Pharmacy &amp; Phone Number:, Row 1' data-aria-label-template='Name of Pharmacy &amp; Phone Number:, Row {0}' type='text' name='input_182[]' value='' /></div><div class='gfield_list_icons gform-grid-col'> <button type='button' aria-label='Add another row' onclick='gformAddListItem(this, 0)' class="add_list_item nitro-lazy">Add</button> <button type='button' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style="visibility:hidden" class="delete_list_item nitro-lazy">Remove</button></div></div></div></div></div></fieldset><div id="field_17_181" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>8. Do you use or take ANY <strong>NON-PRESCRIPTION</strong> medication (including herbal remedies or vitamins)?</p></div><fieldset id="field_17_64" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>8. Do you use or take ANY NON-PRESCRIPTION remedies (including herbal remedies)?</sp
226an><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_64'> <div class='gchoice gchoice_17_64_0'> <input class='gfield-choice-input' name='input_64' type='radio' value='Yes' id='choice_17_64_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_64_0' id='label_17_64_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_64_1'> <input class='gfield-choice-input' name='input_64' type='radio' value='No' id='choice_17_64_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_64_1' id='label_17_64_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_17_193" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_193'><span class='gform-field-label__text'>Please list:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_17_193' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_55" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>9. Are you allergic to any medications?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_55'> <div class='gchoice gchoice_17_55_0'> <input class='gfield-choice-input' name='input_55' type='radio' value='Yes' id='choice_17_55_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_55_0' id='label_17_55_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_55_1'> <input class='gfield-choice-input' name='input_55' type='radio' value='No' id='choice_17_55_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_55_1' id='label_17_55_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_55_2'> <input class='gfield-choice-input' name='input_55' type='radio' value='Not Sure' id='choice_17_55_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_55_2' id='label_17_55_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_56" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_56'><span class='gform-field-label__text'>Please list the medications that you are allergic to:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_17_56' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_195" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>What happened?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_195'> <div class='gchoice gchoice_17_195_0'> <input class='gfield-choice-input' name='input_195' type='radio' value='Rash' id='choice_17_195_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_195_0' id='label_17_195_0' class='gform-field-label gform-field-label--type-inline'>Rash</label> </div> <div class='gchoice gchoice_17_195_1'> <input class='gfield-choice-input' name='input_195' type='radio' value='Breathing problems/Wheezing' id='choice_17_195_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_195_1' id='label_17_195_1' class='gform-field-label gform-field-label--type-inline'>Breathing problems/Wheezing</label> </div> <div class='gchoice gchoice_17_195_2'> <input class='gfield-choice-input' name='input_195' type='radio' value='Swelling' id='choice_17_195_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_195_2' id='label_17_195_2' class='gform-field-label gform-field-label--type-inline'>Swelling</label> </div> <div class='gchoice gchoice_17_195_3'> <input class='gfield-choice-input' name='input_195' type='radio' value='Other' id='choice_17_195_3' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_195_3' id='label_17_195_3' class='gform-field-label gform-field-label--type-inline'>Other</label> </div></div></div></fieldset><div id="field_17_196" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_196'><span class='gform-field-label__text'>Untitled</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_196' id='input_17_196' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_59" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>10. Do you have any other allergies (e.g. latex)?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_59'> <div class='gchoice gchoice_17_59_0'> <input class='gfield-choice-input' name='input_59' type='radio' value='Yes' id='choice_17_59_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_59_0' id='label_17_59_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_59_1'> <input class='gfield-choice-input' name='input_59' type='radio' value='No' id='choice_17_59_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_59_1' id='label_17_59_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_59_2'> <input class='gfield-choice-input' name='input_59' type='radio' value='Not Sure' id='choice_17_59_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_59_2' id='label_17_59_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_60" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_60'><span class='gform-field-label__text'>Please list:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_17_60' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_61" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>11. Do you take any medications for Osteoporosis? (examples Risedronate, Prolia, etc.)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_61'> <div class='gchoice gchoice_17_61_0'> <input class='gfield-choice-input' name='input_61' type='radio' value='Yes' id='choice_17_61_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_61_0' id='label_17_61_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_61_1'> <input class='gfield-choice-input' name='input_61' type='radio' value='No' id='choice_17_61_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_61_1' id='label_17_61_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_61_2'> <input class='gfield-choice-input' name='input_61' type='radio' value='Not Sure' id='choice_17_61_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_61_2' id='label_17_61_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_186" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_186'><span class='gform-field-label__text'>If Prolia, date of last injection:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_17_186' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_186' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_17_186' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_17_186' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_17_186' aria-label='If Prolia, date of last injection:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_17_65" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>12. Do you take 81 mg ASA, daily?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_65'> <div class='gchoice gchoice_17_65_0'> <input class='gfield-choice-input' name='input_65' type='radio' value='Yes' id='choice_17_65_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_65_0' id='label_17_65_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_65_1'> <input class='gfield-choice-input' name='input_65' type='radio' value='No' id='choice_17_65_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_65_1' id='label_17_65_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_65_2'> <input class='gfield-choice-input' name='input_65' type='radio' value='Not Sure' id='choice_17_65_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_65_2' id='label_17_65_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_207" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><span style="font-size:20px;font-weight:700">DO NOT STOP YOUR DAILY ASA</span></div><fieldset id="field_17_177" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>13. Have you taken a cortisone (steroid) type drug orally in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_177'> <div class='gchoice gchoice_17_177_0'> <input class='gfield-choice-input' name='input_177' type='radio' value='Yes' id='choice_17_177_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_177_0' id='label_17_177_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_177_1'> <input class='gfield-choice-input' name='input_177' type='radio' value='No' id='choice_17_177_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_177_1' id='label_17_177_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_177_2'> <input class='gfield-choice-input' name='input_177' type='radio' value='Not Sure' id='choice_17_177_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_177_2' id='label_17_177_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_197" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_197'><span class='gform-field-label__text'>When did it start? How long were you taking it for?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_17_197' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_68" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>14. Do you or any of your relatives have a bleeding problem?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_68'> <div class='gchoice gchoice_17_68_0'> <input class='gfield-choice-input' name='input_68' type='radio' value='Yes' id='choice_17_68_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_68_0' id='label_17_68_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_68_1'> <input class='gfield-choice-input' name='input_68' type='radio' value='No' id='choice_17_68_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_68_1' id='label_17_68_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_68_2'> <input class='gfield-choice-input' name='input_68' type='radio' value='Not Sure' id='choice_17_68_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_68_2' id='label_17_68_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_69" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>15. Do you have or have had any difficulty breathing through your nose?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_69'> <div class='gchoice gchoice_17_69_0'> <input class='gfield-choice-input' name='input_69' type='radio' value='Yes' id='choice_17_69_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_69_0' id='label_17_69_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_69_1'> <input class='gfield-choice-input' name='input_69' type='radio' value='No' id='choice_17_69_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_69_1' id='label_17_69_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_69_2'> <input class='gfield-choice-input' name='input_69' type='radio' value='Not Sure' id='choice_17_69_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_69_2' id='label_17_69_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_70" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>16. Do you have any nose bleeds?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_70'> <div class='gchoice gchoice_17_70_0'> <input class='gfield-choice-input' name='input_70' type='radio' value='Yes' id='choice_17_70_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_70_0' id='label_17_70_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_70_1'> <input class='gfield-choice-input' name='input_70' type='radio' value='No' id='choice_17_70_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_70_1' id='label_17_70_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_70_2'> <input class='gfield-choice-input' name='input_70' type='radio' value='Not Sure' id='choice_17_70_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_70_2' id='label_17_70_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_71" class="gfield gfield--type-text gfield--in
226put-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_71'><span class='gform-field-label__text'>If so, how many per week?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_17_71' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_72" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>17. Do you have or have had any difficulty breathing while sleeping at home?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_72'> <div class='gchoice gchoice_17_72_0'> <input class='gfield-choice-input' name='input_72' type='radio' value='Yes' id='choice_17_72_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_72_0' id='label_17_72_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_72_1'> <input class='gfield-choice-input' name='input_72' type='radio' value='No' id='choice_17_72_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_72_1' id='label_17_72_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_72_2'> <input class='gfield-choice-input' name='input_72' type='radio' value='Not Sure' id='choice_17_72_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_72_2' id='label_17_72_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_75" class="gfield gfield--type-html gfield--input-type-html gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>18. Do you have or have you ever had any of the following? </p></div><fieldset id="field_17_76" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart murmur:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_76'> <div class='gchoice gchoice_17_76_0'> <input class='gfield-choice-input' name='input_76' type='radio' value='Yes' id='choice_17_76_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_76_0' id='label_17_76_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_76_1'> <input class='gfield-choice-input' name='input_76' type='radio' value='No' id='choice_17_76_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_76_1' id='label_17_76_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_76_2'> <input class='gfield-choice-input' name='input_76' type='radio' value='Not Sure' id='choice_17_76_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_76_2' id='label_17_76_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_78" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart attack:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_78'> <div class='gchoice gchoice_17_78_0'> <input class='gfield-choice-input' name='input_78' type='radio' value='Yes' id='choice_17_78_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_78_0' id='label_17_78_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_78_1'> <input class='gfield-choice-input' name='input_78' type='radio' value='No' id='choice_17_78_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_78_1' id='label_17_78_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_78_2'> <input class='gfield-choice-input' name='input_78' type='radio' value='Not Sure' id='choice_17_78_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_78_2' id='label_17_78_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_79" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Chest pain or angina:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_79'> <div class='gchoice gchoice_17_79_0'> <input class='gfield-choice-input' name='input_79' type='radio' value='Yes' id='choice_17_79_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_79_0' id='label_17_79_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_79_1'> <input class='gfield-choice-input' name='input_79' type='radio' value='No' id='choice_17_79_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_79_1' id='label_17_79_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_79_2'> <input class='gfield-choice-input' name='input_79' type='radio' value='Not Sure' id='choice_17_79_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_79_2' id='label_17_79_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_80" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shortness of breath lying down:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_80'> <div class='gchoice gchoice_17_80_0'> <input class='gfield-choice-input' name='input_80' type='radio' value='Yes' id='choice_17_80_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_80_0' id='label_17_80_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_80_1'> <input class='gfield-choice-input' name='input_80' type='radio' value='No' id='choice_17_80_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_80_1' id='label_17_80_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_80_2'> <input class='gfield-choice-input' name='input_80' type='radio' value='Not Sure' id='choice_17_80_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_80_2' id='label_17_80_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_81" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Swollen ankles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_81'> <div class='gchoice gchoice_17_81_0'> <input class='gfield-choice-input' name='input_81' type='radio' value='Yes' id='choice_17_81_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_81_0' id='label_17_81_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_81_1'> <input class='gfield-choice-input' name='input_81' type='radio' value='No' id='choice_17_81_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_81_1' id='label_17_81_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_81_2'> <input class='gfield-choice-input' name='input_81' type='radio' value='Not Sure' id='choice_17_81_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_81_2' id='label_17_81_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_82" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart pacemaker/defibrillator:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_82'> <div class='gchoice gchoice_17_82_0'> <input class='gfield-choice-input' name='input_82' type='radio' value='Yes' id='choice_17_82_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_82_0' id='label_17_82_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_82_1'> <input class='gfield-choice-input' name='input_82' type='radio' value='No' id='choice_17_82_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_82_1' id='label_17_82_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_82_2'> <input class='gfield-choice-input' name='input_82' type='radio' value='Not Sure' id='choice_17_82_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_82_2' id='label_17_82_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_83" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Irregular heart beat/arrhythmia:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_83'> <div class='gchoice gchoice_17_83_0'> <input class='gfield-choice-input' name='input_83' type='radio' value='Yes' id='choice_17_83_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_83_0' id='label_17_83_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_83_1'> <input class='gfield-choice-input' name='input_83' type='radio' value='No' id='choice_17_83_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_83_1' id='label_17_83_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_83_2'> <input class='gfield-choice-input' name='input_83' type='radio' value='Not Sure' id='choice_17_83_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_83_2' id='label_17_83_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_84" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>High blood pressure:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_84'> <div class='gchoice gchoice_17_84_0'> <input class='gfield-choice-input' name='input_84' type='radio' value='Yes' id='choice_17_84_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_84_0' id='label_17_84_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_84_1'> <input class='gfield-choice-input' name='input_84' type='radio' value='No' id='choice_17_84_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_84_1' id='label_17_84_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_84_2'> <input class='gfield-choice-input' name='input_84' type='radio' value='Not Sure' id='choice_17_84_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_84_2' id='label_17_84_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_178" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shingles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_178'> <div class='gchoice gchoice_17_178_0'> <input class='gfield-choice-input' name='input_178' type='radio' value='Yes' id='choice_17_178_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_178_0' id='label_17_178_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_178_1'> <input class='gfield-choice-input' name='input_178' type='radio' value='No' id='choice_17_178_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_178_1' id='label_17_178_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_178_2'> <input class='gfield-choice-input' name='input_178' type='radio' value='Not Sure' id='choice_17_178_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_178_2' id='label_17_178_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_85" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Congenital heart disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_85'> <div class='gchoice gchoice_17_85_0'> <input class='gfield-choice-input' name='input_85' type='radio' value='Yes' id='choice_17_85_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_85_0' id='label_17_85_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_85_1'> <input class='gfield-choice-input' name='input_85' type='radio' value='No' id='choice_17_85_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_85_1' id='label_17_85_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_85_2'> <input class='gfield-choice-input' name='input_85' type='radio' value='Not Sure' id='choice_17_85_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_85_2' id='label_17_85_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_86" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Damaged/abnormal heart valves:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_86'> <div class='gchoice gchoice_17_86_0'> <input class='gfield-choice-input' name='input_86' type='radio' value='Yes' id='choice_17_86_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_86_0' id='label_17_86_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_86_1'> <input class='gfield-choice-input' name='input_86' type='radio' value='No' id='choice_17_86_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_86_1' id='label_17_86_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_86_2'> <input class='gfield-choice-input' name='input_86' type='radio' value='Not Sure' id='choice_17_86_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_86_2' id='label_17_86_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_87" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Rheumatic fever:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_87'> <div class='gchoice gchoice_17_87_0'> <input class='gfield-choice-input' name='input_87' type='radio' value='Yes' id='choice_17_87_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_87_0' id='label_17_87_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_87_1'> <input class='gfield-choice-input' name='input_87' type='radio' value='No' id='choice_17_87_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_87_1' id='label_17_87_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_87_2'> <input class='gfield-choice-input' name='input_87' type='radio' value='Not Sure' id='choice_17_87_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_87_2' id='label_17_87_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_88" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Kidney disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_88'> <div class='gchoice gchoice_17_88_0'> <input class='gfield-choice-input' name='input_88' type='radio' value='Yes' id='choice_17_88_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_88_0' id='label_17_88_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_88_1'> <input class='gfield-choice-input' name='input_88' type='radio' value='No' id='choice_17_88_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_88_1' id='label_17_88_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_88_2'> <input class='gfield-choice-input' name='input_88' type='radio' value='Not Sure' id='choice_17_88_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_88_2' id='label_17_88_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_89" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>HIV, AIDS or STD:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_89'> <div class='gchoice gchoice_17_89_0'> <input class='gfield-choice-input' name='input_89' type='radio' value='Yes' id='choice_17_89_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_89_0' id='label_17_89_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_89_1'> <input class='gfield-choice-input' name='input_89' type='radio' value='No' id='choice_17_89_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_89_1' id='label_17_89_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_89_2'> <input class='gfield-choice-input' name='input_89' type='radio' value='Not Sure' id='choice_17_89_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_89_2' id='label_17_89_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_92" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cancer / Chemotherapy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_92'> <div class='gchoice gchoice_17_92_0'> <input class='gfield-choice-input' name='input_92' type='radio' value='Yes' id='choice_17_92_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_92_0' id='label_17_92_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_92_1'> <input class='gfield-choice-input' name='input_92' type='radio' value='No' id='choice_17_92_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_92_1' id='label_17_92_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_92_2'> <input class='gfield-choice-input' name='input_92' type='radio' value='Not Sure' id='choice_17_92_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_92_2' id='label_17_92_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_93" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been screened for Sleep Apnea?:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_93'> <div class='gchoice gchoice_17_93_0'> <input class='gfield-choice-input' name='input_93' type='radio' value='Yes' id='choice_17_93_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_93_0' id='label_17_93_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_93_1'> <input class='gfield-choice-input' name='input_93' type='radio' value='No' id='choice_17_93_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_93_1' id='label_17_93_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_93_2'> <input class='gfield-choice-input' name='input_93' type='radio' value='Not Sure' id='choice_17_93_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_93_2' id='label_17_93_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_198" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been diagnosed with Sleep Apnea?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_198'> <div class='gchoice gchoice_17_198_0'> <input class='gfield-choice-input' name='input_198' type='radio' value='Yes' id='choice_17_198_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_198_0' id='label_17_198_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_198_1'> <input class='gfield-choice-input' name='input_198' type='radio' value='No' id='choice_17_198_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_198_1' id='label_17_198_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_198_2'> <input class='gfield-choice-input' name='input_198' type='radio' value='Not Sure' id='choice_17_198_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_198_2' id='label_17_198_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_94" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Asthma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_94'> <div class='gchoice gchoice_17_94_0'> <input class='gfield-choice-input' name='input_94' type='radio' value='Yes' id='choice_17_94_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_94_0' id='label_17_94_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_94_1'> <input class='gfield-choice-input' name='input_94' type='radio' value='No' id='choice_17_94_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_94_1' id='label_17_94_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_94_2'> <input class='gfield-choice-input' name='input_94' type='radio' value='Not Sure' id='choice_17_94_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_94_2' id='label_17_94_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_95" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Emphysema / Bronchitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_95'> <div class='gchoice gchoice_17_95_0'> <input class='gfield-choice-input' name='input_95' type='radio' value='Yes' id='choice_17_95_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_95_0' id='label_17_95_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_95_1'> <input class='gfield-choice-input' name='input_95' type='radio' value='No' id='choice_17_95_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_95_1' id='label_17_95_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_95_2'> <input class='gfield-choice-input' name='input_95' type='radio' value='Not Sure' id='choice_17_95_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_95_2' id='label_17_95_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_96" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cystic fibrosis / Tuberculosis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_96'> <div class='gchoice gchoice_17_96_0'> <input class='gfield-choice-input' name='input_96' type='radio' value='Yes' id='choice_17_96_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_96_0' id='label_17_96_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_96_1'> <input class='gfield-choice-input' name='input_96' type='radio' value='No' id='choice_17_96_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_96_1' id='label_17_96_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_96_2'> <input class='gfield-choice-input' name='input_96' type='radio' value='Not Sure' id='choice_17_96_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_96_2' id='label_17_96_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_97" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Epilepsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_97'> <div class='gchoice gchoice_17_97_0'> <input class='gfield-choice-input' name='input_97' type='radio' value='Yes' id='choice_17_97_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_97_0' id='label_17_97_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_97_1'> <input class='gfield-choice-input' name='input_97' type='radio' value='No' id='choice_17_97_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_97_1' id='label_17_97_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_97_2'> <input class='gfield-choice-input' name='input_97' type='radio' value='Not Sure' id='choice_17_97_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_97_2' id='label_17_97_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_98" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stroke:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_98'> <div class='gchoice gchoice_17_98_0'> <input class='gfield-choice-input' name='input_98' type='radio' value='Yes' id='choice_17_98_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_98_0' id='label_17_98_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_98_1'> <input class='gfield-choice-input' name='input_98' type='radio' value='No' id='choice_17_98_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_98_1' id='label_17_98_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_98_2'> <input class='gfield-choice-input' name='input_98' type='radio' value='Not Sure' id='choice_17_98_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_98_2' id='label_17_98_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_99" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Fainting spells, dizziness:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_99'> <div class='gchoice gchoice_17_99_0'> <input class='gfield-choice-input' name='input_99' type='radio' value='Yes' id='choice_17_99_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_99_0' id='label_17_99_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_99_1'> <input class='gfield-choice-input' name='input_99' type='radio' value='No' id='choice_17_99_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_99_1' id='label_17_99_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_99_2'> <input class='gfield-choice-input' name='input_99' type='radio' value='Not Sure' id='choice_17_99_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_99_2' id='label_17_99_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_100" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Diabetes:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_100'> <div class='gchoice gchoice_17_100_0'> <input class='gfield-choice-input' name='input_100' type='radio' value='Yes' id='choice_17_100_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_100_0' id='label_17_100_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_100_1'> <input class='gfield-choice-input' name='input_100' type='radio' value='No' id='choice_17_100_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_100_1' id='label_17_100_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_100_2'> <input class='gfield-choice-input' name='input_100' type='radio' value='Not Sure' id='choice_17_100_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_100_2' id='label_17_100_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_101" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Thyroid Disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_101'> <div class='gchoice gchoice_17_101_0'> <input class='gfield-choice-input' name='input_101' type='radio' value='Yes' id='choice_17_101_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_101_0' id='label_17_101_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_101_1'> <input class='gfield-choice-input' name='input_101' type='radio' value='No' id='choice_17_101_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_101_1' id='label_17_101_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_101_2'> <input class='gfield-choice-input' name='input_101' type='radio' value='Not Sure' id='choice_17_101_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_101_2' id='label_17_101_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_102" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Adrenal gland disorder:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_102'> <div class='gchoice gchoice_17_102_0'> <input class='gfield-choice-input' name='input_102' type='radio' value='Yes' id='choice_17_102_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_102_0' id='label_17_102_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_102_1'> <input class='gfield-choice-input' name='input_102' type='radio' value='No' id='choice_17_102_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_102_1' id='label_17_102_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_102_2'> <input class='gfield-choice-input' name='input_102' type='radio' value='Not Sure' id='choice_17_102_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_102_2' id='label_17_102_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_103" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Hepatitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_103'> <div class='gchoice gchoice_17_103_0'> <input class='gfield-choice-input' name='input_103' type='radio' value='Yes' id='choice_17_103_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_103_0' id='label_17_103_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_103_1'> <input class='gfield-choice-input' name='input_103' type='radio' value='No' id='choice_17_103_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_103_1' id='label_17_103_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_103_2'> <input class='gfield-choice-input' name='input_103' type='radio' value='Not Sure' id='choice_17_103_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_103_2' id='label_17_103_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_104" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Liver disease / Jaundice:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_104'> <div class='gchoice gchoice_17_104_0'> <input class='gfield-choice-input' name='input_104' type='radio' value='Yes' id='choice_17_104_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_104_0' id='label_17_104_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_104_1'> <input class='gfield-choice-input' name='input_104' type='radio' value='No' id='choice_17_104_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_104_1' id='label_17_104_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_104_2'> <input class='gfield-choice-input' name='input_104' type='radio' value='Not Sure' id='choice_17_104_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_104_2' id='label_17_104_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_105" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Anemia (including sickle cell):</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_105'> <div class='gchoice gchoice_17_105_0'> <input class='gfield-choice-input' name='input_105' type='radio' value='Yes' id='choice_17_105_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_105_0' id='label_17_105_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_105_1'> <input class='gfield-choice-input' name='input_105' type='radio' value='No' id='choice_17_105_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_105_1' id='label_17_105_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_105_2'> <input class='gfield-choice-input' name='input_105' type='radio' value='Not Sure' id='choice_17_105_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_105_2' id='label_17_105_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_106" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Blood disorders/transfusions:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_106'> <div class='gchoice gchoice_17_106_0'> <input class='gfield-choice-input' name='input_106' type='radio' value='Yes' id='choice_17_106_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_106_0' id='label_17_106_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_106_1'> <input class='gfield-choice-input' name='input_106' type='radio' value='No' id='choice_17_106_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_106_1' id='label_17_106_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_106_2'> <input class='gfield-choice-input' name='input_106' type='radio' value='Not Sure' id='choice_17_106_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_106_2' id='label_17_106_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_107" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bleeding (Coagulation) disorders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_107'> <div class='gchoice gchoice_17_107_0'> <input class='gfield-choice-input' name='input_107' type='radio' value='Yes' id='choice_17_107_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_107_0' id='label_17_107_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_107_1'> <input class='gfield-choice-input' name='input_107' type='radio' value='No' id='choice_17_107_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_107_1' id='label_17_107_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_107_2'> <input class='gfield-choice-input' name='input_107' type='radio' value='Not Sure' id='choice_17_107_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_107_2' id='label_17_107_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_108" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stomach ulcers/ Acid Reflux:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_108'> <div class='gchoice gchoice_17_108_0'> <input class='gfield-choice-input' name='input_108' type='radio' value='Yes' id='choice_17_108_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_108_0' id='label_17_108_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_108_1'> <input class='gfield-choice-input' name='input_108' type='radio' value='No' id='choice_17_108_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_108_1' id='label_17_108_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_108_2'> <input class='gfield-choice-input' name='input_108' type='radio' value='Not Sure' id='choice_17_108_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_108_2' id='label_17_108_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_109" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bone, joint, or muscle problems:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_109'> <div class='gchoice gchoice_17_109_0'> <input class='gfield-choice-input' name='input_109' type='radio' value='Yes' id='choice_17_109_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_109_0' id='label_17_109_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_109_1'> <input class='gfield-choice-input' name='input_109' type='radio' value='No' id='choice_17_109_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_109_1' id='label_17_109_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_109_2'> <input class='gfield-choice-input' name='input_109' type='radio' value='Not Sure' id='choice_17_109_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_109_2' id='label_17_109_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_110" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Artificial joints - hips, knees, shoulders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_110'> <div class='gchoice gchoice_17_110_0'> <input class='gfield-choice-input' name='input_110' type='radio' value='Yes' id='choice_17_110_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_110_0' id='label_17_110_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_110_1'> <input class='gfield-choice-input' name='input_110' type='radio' value='No' id='choice_17_110_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_110_1' id='label_17_110_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_110_2'> <input class='gfield-choice-input' name='input_110' type='radio' value='Not Sure' id='choice_17_110_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_110_2' id='label_17_110_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_187" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_187'><span class='gform-field-label__text'>Date of replacement:</span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_17_187' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_187' value='' aria-invalid="false" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_17_187' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_17_187' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_17_187' aria-label='Date of replacement:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_17_111" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Arthritis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_111'> <div class='gchoice gchoice_17_111_0'> <input class='gfield-choice-input' name='input_111' type='radio' value='Yes' id='choice_17_111_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_111_0' id='label_17_111_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_111_1'> <input class='gfield-choice-input' name='input_111' type='radio' value='No' id='choice_17_111_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_111_1' id='label_17_111_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_111_2'> <input class='gfield-choice-input' name='input_111' type='radio' value='Not Sure' id='choice_17_111_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_111_2' id='label_17_111_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_112" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Depression / anxiety:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_112'> <div class='gchoice gchoice_17_112_0'> <input class='gfield-choice-input' name='input_112' type='radio' value='Yes' id='choice_17_112_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_112_0' id='label_17_112_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_112_1'> <input class='gfield-choice-input' name='input_112' type='radio' value='No' id='choice_17_112_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_112_1' id='label_17_112_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_112_2'> <input class='gfield-choice-input' name='input_112' type='radio' value='Not Sure' id='choice_17_112_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_112_2' id='label_17_112_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_113" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Vision problems / glaucoma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_113'> <div class='gchoice gchoice_17_113_0'> <input class='gfield-choice-input' name='input_113' type='radio' value='Yes' id='choice_17_113_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_113_0' id='label_17_113_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_113_1'> <input class='gfield-choice-input' name='input_113' type='radio' value='No' id='choice_17_113_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_113_1' id='label_17_113_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_113_2'> <input class='gfield-choice-input' name='input_113' type='radio' value='Not Sure' id='choice_17_113_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_113_2' id='label_17_113_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_114" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>People with intellectual/cognitive disabilities:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_114'> <div class='gchoice gchoice_17_114_0'> <input class='gfield-choice-input' name='input_114' type='radio' value='Yes' id='choice_17_114_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_114_0' id='label_17_114_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_114_1'> <input class='gfield-choice-input' name='input_114' type='radio' value='No' id='choice_17_114_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_114_1' id='label_17_114_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_114_2'> <input class='gfield-choice-input' name='input_114' type='radio' value='Not Sure' id='choice_17_114_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_114_2' id='label_17_114_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_115" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cerebral palsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_115'> <div class='gchoice gchoice_17_115_0'> <input class='gfield-choice-input' name='input_115' type='radio' value='Yes' id='choice_17_115_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_115_0' id='label_17_115_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_115_1'> <input class='gfield-choice-input' name='input_115' type='radio' value='No' id='choice_17_115_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_115_1' id='label_17_115_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_115_2'> <input class='gfield-choice-input' name='input_115' type='radio' value='Not Sure' id='choice_17_115_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_115_2' id='label_17_115_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_116" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Autism or Down&#039;s syndrome:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_116'> <div class='gchoice gchoice_17_116_0'> <input class='gfield-choice-input' name='input_116' type='radio' value='Yes' id='choice_17_116_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_116_0' id='label_17_116_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_116_1'> <input class='gfield-choice-input' name='input_116' type='radio' value='No' id='choice_17_116_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_116_1' id='label_17_116_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_116_2'> <input class='gfield-choice-input' name='input_116' type='radio' value='Not Sure' id='choice_17_116_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_116_2' id='label_17_116_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_117" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_117'> <div class='gchoice gchoice_17_117_0'> <input class='gfield-choice-input' name='input_117' type='radio' value='Yes' id='choice_17_117_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_117_0' id='label_17_117_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_117_1'> <input class='gfield-choice-input' name='input_117' type='radio' value='No' id='choice_17_117_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_117_1' id='label_17_117_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_117_2'> <input class='gfield-choice-input' name='input_117' type='radio' value='Not Sure' id='choice_17_117_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_117_2' id='label_17_117_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_118" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you a nursing mother?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_118'> <div class='gchoice gchoice_17_118_0'> <input class='gfield-choice-input' name='input_118' type='radio' value='Yes' id='choice_17_118_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_118_0' id='label_17_118_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_118_1'> <input class='gfield-choice-input' name='input_118' type='radio' value='No' id='choice_17_118_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_118_1' id='label_17_118_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_118_2'> <input class='gfield-choice-input' name='input_118' type='radio' value='Not Sure' id='choice_17_118_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_118_2' id='label_17_118_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_119" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Any problems with menstruation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_119'> <div class='gchoice gchoice_17_119_0'> <input class='gfield-choice-input' name='input_119' type='radio' value='Yes' id='choice_17_119_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_119_0' id='label_17_119_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_119_1'> <input class='gfield-choice-input' name='input_119' type='radio' value='No' id='choice_17_119_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_119_1' id='label_17_119_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_119_2'> <input class='gfield-choice-input' name='input_119' type='radio' value='Not Sure' id='choice_17_119_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_119_2' id='label_17_119_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_120" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>19. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_120'> <div class='gchoice gchoice_17_120_0'> <input class='gfield-choice-input' name='input_120' type='radio' value='Yes' id='choice_17_120_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_120_0' id='label_17_120_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_120_1'> <input class='gfield-choice-input' name='input_120' type='radio' value='No' id='choice_17_120_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_120_1' id='label_17_120_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_120_2'> <input class='gfield-choice-input' name='input_120' type='radio' value='Not Sure' id='choice_17_120_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_120_2' id='label_17_120_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_121" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>20. Do you have any problems opening your mouth wide or moving your neck fully?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_121'> <div class='gchoice gchoice_17_121_0'> <input class='gfield-choice-input' name='input_121' type='radio' value='Yes' id='choice_17_121_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_121_0' id='label_17_121_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_121_1'> <input class='gfield-choice-input' name='input_121' type='radio' value='No' id='choice_17_121_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_121_1' id='label_17_121_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_121_2'> <input class='gfield-choice-input' name='input_121' type='radio' value='Not Sure' id='choice_17_121_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_121_2' id='label_17_121_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_122" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>21. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_122'> <div class='gchoice gchoice_17_122_0'> <input class='gfield-choice-input' name='input_122' type='radio' value='Yes' id='choice_17_122_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_122_0' id='label_17_122_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_122_1'> <input class='gfield-choice-input' name='input_122' type='radio' value='No' id='choice_17_122_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_122_1' id='label_17_122_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_122_2'> <input class='gfield-choice-input' name='input_122' type='radio' value='Not Sure' id='choice_17_122_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_122_2' id='label_17_122_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_188" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_188'><span class='gform-field-label__text'>When?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_17_188' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_188' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_17_188' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_17_188' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_17_188' aria-label='When?: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><div id="field_17_189" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_189'><span class='gform-field-label__text'>Where?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_17_189' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_17_206" class="gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_206'><span class='gform-field-label__text'>Name of oncologist:</span></label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_17_206' type='text' value='' class='large' aria-invalid="false" /></div></div><fieldset id="field_17_123" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>22. Do you smoke?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_123'> <div class='gchoice gchoice_17_123_0'> <input class='gfield-choice-input' name='input_123' type='radio' value='Yes' id='choice_17_123_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_123_0' id='label_17_123_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_123_1'> <input class='gfield-choice-input' name='input_123' type='radio' value='No' id='choice_17_123_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_123_1' id='label_17_123_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_123_2'> <input class='gfield-choice-input' name='input_123' type='radio' value='Not Sure' id='choice_17_123_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_123_2' id='label_17_123_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_125" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_125'><span class='gform-field-label__text'>If so how much?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_17_125' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_124" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>23. Do you drink more than 5 alcoholic beverages per week? Number/week</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_124'> <div class='gchoice gchoice_17_124_0'> <input class='gfield-choice-input' name='input_124' type='radio' value='Yes' id='choice_17_124_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_124_0' id='label_17_124_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_124_1'> <input class='gfield-choice-input' name='input_124' type='radio' value='No' id='choice_17_124_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_124_1' id='label_17_124_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_124_2'> <input class='gfield-choice-input' name='input_124' type='radio' value='Not Sure' id='choice_17_124_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_124_2' id='label_17_124_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_126" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_126'><span class='gform-field-label__text'>Number/week</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_17_126' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_17_127" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>24. Do you have a history of alcoholism or drug dependence or substance abuse?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_127'> <div class='gchoice gchoice_17_127_0'> <input class='gfield-choice-input' name='input_127' type='radio' value='Yes' id='choice_17_127_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_127_0' id='label_17_127_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_127_1'> <input class='gfield-choice-input' name='input_127' type='radio' value='No' id='choice_17_127_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_127_1' id='label_17_127_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_127_2'> <input class='gfield-choice-input' name='input_127' type='radio' value='Not Sure' id='choice_17_127_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_127_2' id='label_17_127_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_128" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>25. Have you taken any recreational drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, crystal meth, codeine, oxycodone or other drugs?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_128'> <div class='gchoice gchoice_17_128_0'> <input class='gfield-choice-input' name='input_128' type='radio' value='Yes' id='choice_17_128_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_128_0' id='label_17_128_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_128_1'> <input class='gfield-choice-input' name='input_128' type='radio' value='No' id='choice_17_128_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_128_1' id='label_17_128_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_128_2'> <input class='gfield-choice-input' name='input_128' type='radio' value='Not Sure' id='choice_17_128_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_128_2' id='label_17_128_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_17_129" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>26. Do you have ANY disease, condition or problem not listed above?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_17_129'> <div class='gchoice gchoice_17_129_0'> <input class='gfield-choice-input' name='input_129' type='radio' value='Yes' id='choice_17_129_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_129_0' id='label_17_129_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_17_129_1'> <input class='gfield-choice-input' name='input_129' type='radio' value='No' id='choice_17_129_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_129_1' id='label_17_129_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_17_129_2'> <input class='gfield-choice-input' name='input_129' type='radio' value='Not Sure' id='choice_17_129_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_17_129_2' id='label_17_129_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_17_130" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_130'><span class='gform-field-label__text'>Explain:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_130' id='input_17_130' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_17_131" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_131'><span class='gform-field-label__text'>What&#039;s your weight (lbs)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_17_131' type='text' value='' class='large' placeholder='999' aria-required="true" aria-invalid="false" data-mask="999" /></div></div><div id="field_17_174" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>What's your height?</p></div><div id="field_17_175" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_left_half gf_color gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_175'><span class='gform-field-label__text'>Feet</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_175' id='input_17_175' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option></select></div></div><div id="field_17_176" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_right_half gf_color gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_176'><span class='gform-field-label__text'>Inches</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_176' id='input_17_176' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11.5'>11.5</option></select></div></div><div id="field_17_134" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_17_134'><span class='gform-field-label__text'>Any additional information you wish to convey to Dr. Kumer please explain below:</span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_17_134' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_17_184" class="gfield gfield--type-signature gfield--in
226put-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Signature</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_container ginput_container_signature"><input type='hidden' value='' name='input_184' id='input_17_184_signature_filename' class='gfield_signature_filename' /><div class='gfield_signature_ui_container gform-theme__no-reset--children'><div id='input_17_184_Container' class='gfield_signature_container' style='height:90px;width:300px'><input type='hidden' id='input_17_184_data' name='input_17_184_data' class='gfield_signature_data' /><canvas id="input_17_184" width="300" height="90" style="border-style:Dashed;border-width:2px;border-color:#757575;background-color:#fff;cursor:url(&quot;https://summitheightsdental.com/nitropack_static/FvibRvOpvKUPQoFPcmVkuTtolIergKoe/assets/desktop/source/rev-c5c7266/summitheightsdental.com/wp-content/plugins/gravityformssignature/assets/img/pen.cur&quot;),pointer" tabindex="0" aria-label="Signature pad"></canvas><input type='text' id='input_17_184_textinput' name='input_17_184_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:300px;height:90px;border-style:Dashed;border-width:2px;border-color:#757575;background-color:#fff;font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#000' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' /></div><div id='input_17_184_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:300px;max-width:100%;display:flex;align-items:center'><div id='input_17_184_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0'></div><input type='hidden' id='input_17_184_font_select' class='gfield_signature_font_select' value='script' /><div id='input_17_184_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'></span><button type='button' id='input_17_184_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;color:#000'>Your Name</button><ul id='input_17_184_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;color:#000' aria-label='Your Name, Script style'>Your Name</li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;,&quot;Comic Sans MS&quot;,cursive;color:#000' aria-label='Your Name, Handwritten style'>Your Name</li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;,&quot;Segoe Print&quot;,cursive;color:#000' aria-label='Your Name, Print style'>Your Name</li></ul></div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center'><button type='button' id='input_17_184_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Text Signature' aria-label='Text Signature'></button><button type='button' id='input_17_184_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Draw Signature' aria-label='Draw Signature'></button><button type='button' id='input_17_184_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Clear Signature' aria-label='Clear Signature'></button></div></div></div></div></fieldset><fieldset id="field_17_185" class="gfield gfield--type-consent gfield--type-choice gfield--in
226put-type-consent gfield--width-full pri-check gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Consent</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_consent'><input name='input_185.1' id='input_17_185_1' type='checkbox' value='1' aria-required="true" aria-invalid="false" /> <label class="gform-field-label gform-field-label--type-inline gfield_consent_label" for='input_17_185_1'><span class='gform-field-label__text'>By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our <a href="/privacy-policy/">Privacy Policy</a>.</span><span class="gfield_required gfield_required_asterisk">*</span></label><input type='hidden' name='input_185.2' value='By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our &lt;a href=&quot;/privacy-policy/&quot;&gt;Privacy Policy&lt;/a&gt;.' class='gform_hidden' /><input type='hidden' name='input_185.3' value='9' class='gform_hidden' /></div></fieldset></div></div> <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_17' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='submit' id='gform_submit_button_17' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit'>Submit</button> <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_17' value='postback' /> <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_17' id='gform_theme_17' value='gravity-theme' /> <input type='hidden' class='gform_hidden' 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top&quot;,&quot;position_from_trigger&quot;:false,&quot;position_top&quot;:&quot;100&quot;,&quot;position_left&quot;:&quot;0&quot;,&quot;position_bottom&quot;:&quot;0&quot;,&quot;position_right&quot;:&quot;0&quot;,&quot;position_fixed&quot;:false,&quot;animation_type&quot;:&quot;fade&quot;,&quot;animation_speed&quot;:&quot;350&quot;,&quot;animation_origin&quot;:&quot;center top&quot;,&quot;overlay_zindex&quot;:false,&quot;zindex&quot;:&quot;1999999999&quot;},&quot;close&quot;:{&quot;text&quot;:&quot;&quot;,&quot;button_delay&quot;:&quot;0&quot;,&quot;overlay_click&quot;:false,&quot;esc_press&quot;:false,&quot;f4_press&quot;:false},&quot;click_open&quot;:[]}}"> <div id="popmake-539" class="pum-container popmake theme-528 pum-responsive pum-responsive-small responsive size-small"> <div class="pum-content popmake-content" tabindex="0"> <div class='gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_12' style='display:none'><div id='gf_12' class='gform_anchor' tabindex='-1'></div> <div class='gform_heading'> <p class='gform_required_legend'>&quot;
226<span class="gfield_required gfield_required_asterisk">*</span>&quot; indicates required fields</p> </div><form method='post' enctype='multipart/form-data' id='gform_12' action='/locations/#gf_12' data-formid='12' novalidate> <div id='gf_progressbar_wrapper_12' class='gf_progressbar_wrapper' data-start-at-zero=''> <p class="gf_progressbar_title">Step <span class='gf_step_current_page'>1</span> of <span class='gf_step_page_count'>9</span><span class='gf_step_page_name'></span> </p> <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'> <div class='gf_progressbar_percentage percentbar_blue percentbar_11' style='width:11%'><span>11%</span></div> </div></div> <div class='gform-body gform_body'><div id='gform_page_12_1' class='gform_page ' data-js='page-field-id-0'> <div class='gform_page_fields'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_198" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH</h5> <h5>WHAT IS AN IMPACTED TOOTH?</h5> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <h5>WHAT HARM CAN IMPACTED TEETH DO?</h5> <p></p><ol><li>Impacted teeth may grow in any direction; however they often grow forward and push against the adjacent second molar. This can result in pain in the second molar and possibly damage to the roots or crown. The second molar may also be pushed out of position.</li> <li>All teeth develop in sacs deep in the bone. If the tooth erupts normally, the sac generally disappears. If the tooth is impacted, the sac can fill with fluid and enlarge to form a cyst. The cyst can cause destruction of surrounding bone and damage to other teeth in the area.</li> <li>Whenever saliva can reach the tooth, decay may occur, and since such cavities cannot be filled severe pain may result. This may be followed by the formation of an abscess.</li> <li>Bacteria in the saliva may cause an infection around the crown of the wisdom tooth and under the flap of gum tissue which may be covering part of the tooth. This infection may spread to the cheek, throat or neck and result in severe pain, stiffness of the jaws, fever, and severe generalized illness.</li> <li>Pressure from the wisdom teeth may cause crowding of the front teeth. This is why some orthodontists do not consider orthodontic treatment complete until impacted third molars have been removed.</li></ol><p></p> <h5>WHEN IS IT BEST TO HAVE WISDOM TEETH REMOVED?</h5> <p>The dentist can study x-rays of the teeth and jaws, and can frequently tell by the teen years if the wisdom teeth are going to be impacted. At this stage the roots are usually not fully formed in most people and the bone is less dense. Therefore, the wisdom teeth are less complicated to remove and the healing is generally faster.</p> <h5>WHAT IS IT LIKE TO HAVE AN IMPACTED TOOTH REMOVED?</h5> <p>Because the impacted tooth is usually completely beneath the surface of the gum and often encased in bone, we consider its removal an operation in every sense of the word. This is said not to frighten the prospective patient, but rather to give a better understanding about certain features regarding cost, careful preparations and the need for good aftercare. Either local and general anaesthesia or local and sedation may be used. The dentist chooses the method of treatment based on each individual situation. Having a comfortable patient helps to control bleeding, allows the dentist to work without haste and causes less physiological disturbance to the patient. The actual removal of the tooth is done in keeping with recognized surgical principles, with meticulously sterile instruments, good light, a dry operative field, gentle handling of the soft tissue and bone and the advantages of a well trained team. Depending on the degree of difficulty of the individual case, the procedure may last from fifteen to sixty minutes. If sedation or general anaesthesia is used there will be a recovery period from thirty to ninety minutes. The surgical wound may be sutured with a material of the dentist’s choice. Most often dissolving sutures are used.<
226/p> <h5>WHAT SHOULD I EXPECT AFTER SURGERY?</h5> <p>After any surgical procedure a certain amount of discomfort is anticipated. For this reason you will be provided with pain relieving medication before you leave the office. You are to take your pain medication as directed by the dentist; instructions will be on the bottle. Your dentist will decide if antibiotic medication is necessary and if this medication has been prescribed then it should be taken until all tablets are gone. Swelling after surgery is normal. You should expect to be most swollen forty eight to seventy two hours after surgery. The swelling then begins to resolve. Certain individuals have bruising after wisdom teeth surgery. The bruising may extend into the neck and chest. This should not alarm you as in some individuals this is the normal sequence of events.</p> <p>Stiffness of the jaws is also normal after wisdom teeth surgery and is usually at its worst two or three days after surgery. One should start to exercise the jaws on the second or third post operative day to return the jaws to normal.</p> <p>Although it will probably be difficult to eat after surgery in the mouth one must remember that the body heals itself by drawing upon its reserves of protein, vitamins, minerals, calcium and iron. Failure to replenish the body’s supplies of the above mentioned nutrients can result in fatigue, infections and even delayed healing. For the first twenty-four hours following surgery your food and beverages should be warm or cold NOT HOT. Eggs, custards, yogurt, milkshakes, baby food, etc., are both nutritious and manageable. Fluid intake should be approximately two litres or eight juice glasses per day for the average adult.</p> <p>Detailed post operative instructions will be provided before you leave the office.</p> <h5>ARE THERE ANY COMPLICATIONS OR RISKS?</h5> <p>Any operation carries some degree of risk. This risk is minimized by careful preoperative assessment of your physical condition, by careful examination of all of the diagnostic materials, by careful preparation of instruments and all facilities, and by the skill of your dental team. The most commonly encountered complications will be discussed below.</p> <p>Post-operative bleeding is usually encountered when the patient has not placed the gauze pack DIRECTLY over the surgical site. Pressure over the site for forty-five to sixty minutes will control most post-operative bleeding. If you are still concerned call the office and the problem will be dealt with promptly.</p> <p>A condition known as dry socket occurs in approximately five percent of patients. It is more common in smokers and in female patients on the pill. It is manifest by a dull throbbing pain which starts five or seven days after the operation and is accompanied by a foul odour from the mouth. The treatment for this problem is simple and consists of two or three dressing changes. Healing is slightly slower than normal.</p> <p>The roots of lower impacted teeth very often rest on and around the main nerve of the lower jaw. Very rarely, in spite of all precautions, during the removal of lower third molars this nerve is bruised, slightly lacerated or even severed. The result will be numbness of the lower lip, chin, and all of the teeth on that side. This effect does not last longer than a few weeks in most cases. It improves as the nerve repairs itself and regenerates. Occasionally the numbness may last as long as two or five years and even more rarely it may be permanent .Also in the region of the lower third molar is the nerve which supplies sensation to the lateral part of the tongue. It may on occasion be stretched with a resultant numb tongue. This problem usually resolves within several weeks or months. Upper impacted third molars lie against the wall of the sinus. Great care is taken to insure that no injury occurs to this structure but occasionally the thin wall of bone cracks and blood seeps into the sinus. Occasionally there may be formed a communication between the sinus and the mouth. If your dentist suspects this to be the case you will be informed and additional medication will be prescribed. Infections after the removal of wisdom teeth are rare. Redness, increasing swelling after an initial decrease, foul tasting discharge into the mouth, fever and chills are all signs if infection. If these should appear call the office and you will be attended to promptly.</p> <p>Occasionally large fillings in the second molar teeth may be loosened or cracked during the removal of the wisdom teeth in spite of immaculate care and skill. If the possibility of this exists prior to surgery, you will be informed.</p> <p>Another very rare complication is a cracked or fractured lower jaw. This occurs when the wisdom tooth is very severely impacted. If your dentist is concerned about this possibility, you will be informed.</p> <p>Dr. Brian Kumer<br /><a href="tel:4166050008">(416) 605-0008</a></p></div><fieldset id="field_12_138" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>I acknowledge that I have read this document</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_138'><div class='gchoice gchoice_12_138_1'> <input class='gfield-choice-input' name='input_138.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_138_1' /> <label for='choice_12_138_1' id='label_12_138_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_12_4' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_2' class='gform_page' data-js='page-field-id-4' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_199" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ORAL SURGERY CONSENT FORM</h5> <h5>SWELLING, BRUISING AND PAIN</h5> <p>These can occur with any surgery and vary between patients and from one surgery to another. You may require several days at home for recovery. You may also have stretching of the corners of the mouth that may cause bruising and may heal slowly.</p></div><fieldset id="field_12_200" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SWELLING, BRUISING AND PAIN</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_200'><div class='gchoice gchoice_12_200_1'> <input class='gfield-choice-input' name='input_200.1' type='checkbox' value='I have read and understand this section.' id='choice_12_200_1' /> <label for='choice_12_200_1' id='label_12_200_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_201" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TRISMUS</h5> <p>This is the limited opening of the jaws due to inflammation in the muscles. This is more common with impacted tooth removal but is possible with almost any surgery. There is a higher likelihood if TMJ (see below) problem already exists.</p></div><fieldset id="field_12_203" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TRISMUS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_203'><div class='gchoice gchoice_12_203_1'> <input class='gfield-choice-input' name='input_203.1' type='checkbox' value='I have read and understand this section.' id='choice_12_203_1' /> <label for='choice_12_203_1' id='label_12_203_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_204" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INFECTION</h5> <p>This is possible with any surgical procedure and may require further surgery and/or medications if it does occur.</p></div><fieldset id="field_12_205" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFECTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_205'><div class='gchoice gchoice_12_205_1'> <input class='gfield-choice-input' name='input_205.1' type='checkbox' value='I have read and understand this section.' id='choice_12_205_1' /> <label for='choice_12_205_1' id='label_12_205_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_206" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>BLEEDING</h5> <p>Although significant bleeding can occur during or after surgery, it is not common. Some bleeding is, however, expected with most surgeries and is normally controlled by following the post-op instruction sheet. Prolonged or heavy bleeding may require additional treatment.</p></div><fieldset id="field_12_207" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>BLEEDING</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_207'><div class='gchoice gchoice_12_207_1'> <input class='gfield-choice-input' name='input_207.1' type='checkbox' value='I have read and understand this section.' id='choice_12_207_1' /> <label for='choice_12_207_1' id='label_12_207_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_209" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TMJ DYSFUNCTION</h5> <p>This means the jaw joint (Tempromandibular Joint) may not function properly and, although rare, may require treatment ranging from use of hot/cold compress and rest to further surgery.</p></div><fieldset id="field_12_208" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TMJ DYSFUNCTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_208'><div class='gchoice gchoice_12_208_1'> <input class='gfield-choice-input' name='input_208.1' type='checkbox' value='I have read and understand this section.' id='choice_12_208_1' /> <label for='choice_12_208_1' id='label_12_208_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_210" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>LOCAL ANAESTHESIA</h5> <p>Certain possible risks exist that, although uncommon or rare, could include pain, swelling, bruising, infection, nerve damage, idiosyncratic or allergic reactions.</p></div><fieldset id="field_12_213" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>LOCAL ANAESTHESIA</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_213'><div class='gchoice gchoice_12_213_1'> <input class='gfield-choice-input' name='input_213.1' type='checkbox' value='I have read and understand this section.' id='choice_12_213_1' /> <label for='choice_12_213_1' id='label_12_213_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_212" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ALLERGIC REACTION</h5> <p>Allergic reaction, such as itching, rash, swelling, difficulty in breathing, is possible to any medication used it treatment.</p></div><fieldset id="field_12_211" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>ALLERGIC REACTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_211'><div class='gchoice gchoice_12_211_1'> <input class='gfield-choice-input' name='input_211.1' type='checkbox' value='I have read and understand this section.' id='choice_12_211_1' /> <label for='choice_12_211_1' id='label_12_211_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_214" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DRY SOCKET</h5> <p>This is significant pain in the jaw and ear due to the loss of the blood clot and most commonly occurs after the removal of lower wisdom teeth, but it is possible with any extractions. Incidence increases with poor oral hygiene, smoking, birth control pill use. This may require additional office visits to treat.</p></div><fieldset id="field_12_215" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DRY SOCKET</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_215'><div class='gchoice gchoice_12_215_1'> <input class='gfield-choice-input' name='input_215.1' type='checkbox' value='I have read and understand this section.' id='choice_12_215_1' /> <label for='choice_12_215_1' id='label_12_215_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_218" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DAMAGE TO OTHER TEETH AND FILLINGS</h5> <p>Due to the close proximity of teeth, it is possible to damage other teeth and/or fillings when a tooth is removed</p></div><fieldset id="field_12_217" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DAMAGE TO OTHER TEETH AND FILLINGS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_217'><div class='gchoice gchoice_12_217_1'> <input class='gfield-choice-input' name='input_217.1' type='checkbox' value='I have read and understand this section.' id='choice_12_217_1' /> <label for='choice_12_217_1' id='label_12_217_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_219" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SHARP RIDGES AND BONE SPLINTERS</h5> <p>Occasionally, after an extraction, the edge of the socket will be sharp or a bone splinter will come out through the gum. This may require another surgery to smooth or remove the bone splinter.</p></div><fieldset id="field_12_220" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SHARP RIDGES AND BONE SPLINTERS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_220'><div class='gchoice gchoice_12_220_1'> <input class='gfield-choice-input' name='input_220.1' type='checkbox' value='I have read and understand this section.' id='choice_12_220_1' /> <label for='choice_12_220_1' id='label_12_220_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_221" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</h5> <p>There are times when the dentist may decide to leave in a fragment or root of a tooth in order to avoid doing damage to adjacent structures such as nerves, sinuses, etc. or if an extensive risk of other complications is present with its removal.</p></div><fieldset id="field_12_222" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_222'><div class='gchoice gchoice_12_222_1'> <input class='gfield-choice-input' name='input_222.1' type='checkbox' value='I have read and understand this section.' id='choice_12_222_1' /> <label for='choice_12_222_1' id='label_12_222_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_223" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>NUMBNESS</h5> <p>Due to the proximity of roots to the nerve (especially wisdom teeth), it is possible to bruise or damage the nerve with removal of a tooth. This could remain for days, weeks, or very rarely, permanently. The lip, chin, cheek, gums and/or tongue could feel numb, tingling or have burning sensation.</p></div><fieldset id="field_12_225" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>NUMBNESS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_225'><div class='gchoice gchoice_12_225_1'> <input class='gfield-choice-input' name='input_225.1' type='checkbox' value='I have read and understand this section.' id='choice_12_225_1' /> <label for='choice_12_225_1' id='label_12_225_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_226" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SINUS INVOLVEMENT</h5> <p>Due to the location of the roots (especially the upper back teeth) to the sinus, it is possible for an opening to develop from the sinus to the mouth. Or a tooth/fragment may be displaced into the sinus. A possible infection and/or permanent opening from the mouth into the sinus could develop and may require medication and/ or later surgery.</p></div><fieldset id="field_12_229" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SINUS INVOLVEMENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_229'><div class='gchoice gchoice_12_229_1'> <input class='gfield-choice-input' name='input_229.1' type='checkbox' value='I have read and understand this section.' id='choice_12_229_1' /> <label for='choice_12_229_1' id='label_12_229_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_228" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>JAW FRACTURE</h5> <p>Fracture of the jaw, usually in more complicated extractions.</p></div><fieldset id="field_12_227" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>JAW FRACTURE</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_227'><div class='gchoice gchoice_12_227_1'> <input class='gfield-choice-input' name='input_227.1' type='checkbox' value='I have read and understand this section.' id='choice_12_227_1' /> <label for='choice_12_227_1' id='label_12_227_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_12_137" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>QUALIFICATION</h5> <p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions, and including wisdom teeth and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p></div><fieldset id="field_12_139" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>QUALIFICATION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_139'><div class='gchoice gchoice_12_139_1'> <input class='gfield-choice-input' name='input_139.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_139_1' /> <label for='choice_12_139_1' id='label_12_139_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_3' class='gform_page' data-js='page-field-id-7' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_9" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h3></div><div id="field_12_162" class="gfield gfield--type-html gfield--in
226put-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_12_160" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_12_164" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_164'><div class='gchoice gchoice_12_164_1'> <input class='gfield-choice-input' name='input_164.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_164_1' /> <label for='choice_12_164_1' id='label_12_164_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_4' class='gform_page' data-js='page-field-id-15' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_16" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p><b>Ontario’s Narcotics Strategy</b></p> <p><b>List Of Approved Forms Of Identification</b></p> <p> </p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul><p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li>Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Canadian Immigration Identification Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>Royal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_12_141" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_141'><div class='gchoice gchoice_12_141_1'> <input class='gfield-choice-input' name='input_141.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_141_1' /> <label for='choice_12_141_1' id='label_12_141_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_5' class='gform_page' data-js='page-field-id-18' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_19" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST-OPERATIVE INSTRUCTIONS</h5> <h5 style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></h5> <p style="text-align:center">PLEASE READ THESE INSTRUCTIONS CAREFULLY. Sometimes the after effects of oral surgery are quite minimal, so not all of these instructions may apply to you. Common sense will dictate what you should do. However, when in doubt, follow these guidelines or call us for advice.</p> <p style="text-align:center">DAY OF SURGERY (FIRST 24 HRS)</p> <p style="text-align:center">AND DAYS 2-7</p> <h5>FIRST HOUR</h5> <p>Bite down gently but firmly on the gauze packs that have been placed on the surgical sites, making sure they remain in place. Do not change them for the first 30 minutes unless the bleeding is not being controlled. If active bleeding persists after 30 minutes, place enough new gauze to obtain pressure over the surgical site for another 30 minutes. The gauze may be changed as necessary and may be dampened for more comfortable positioning. Do not disturb the surgical area today.NO RINSING, WHATSOEVER, DURING THIS PHASE. DO NOT SMOKE. Smoking increases the risk of dry socket dramatically.</p> <h5>OOZING/BLEEDING</h5> <p>It’s normal to have your saliva stained with blood for a few days. There may also be some slight oozing. If this persists, place fresh gauze over the area and bite down for 30-60 minutes. Bleeding should never be severe. If it is, it usually means the gauze packs are placed between your teeth and not over the surgical sites. Try to reposition them. If this doesn’t work substitute a moistened tea bag wrapped in moist gauze for 30-60 minutes. Do not sleep with gauze in your mouth.When sleeping use an old pillow and place some towels around your head to protect your bedding. If bleeding remains uncontrolled please call us.</p> <h5>SWELLING</h5> <p>Often there is swelling/bruising associated with oral surgery. Swelling is a normal response to trauma. It is not the same as infection. If you are swollen this does not mean you are infected. You can minimize this by using an ice pack applied to the face adjacent to the surgical site. The ice should be applied for a 10 minutes per side every hour over a 24-48 hour period. After the first 24-48 hours, stop icing the area. Do not use ice packs while sleeping. Despite icing the area, swelling will still occur. After 48 hours, apply a warm moist compress for 10-15 min of several times a day for balance of the week. Swelling usually increases over a 72 hour period. Therefore you will appear more swollen on the 3rd day than the 2nd day. After 72 hours, swelling starts to slowly subside and is mostly gone by the 7th day.</p> <h5>RINSING</h5> <p>After the first 48 hours have elapsed you may stop icing the area. At this time start with warm salt water rinse. Place a teaspoon of salt in a glass of warm water. Gently swish it around your mouth 2-3 times a day for the next 7-10 days. Do not spit out the rinse. Let it fall out of your mouth. Spitting exerts a force on the healing clot and can slow down healing and promote bleeding. Do not use mouthwash for the first 7 days unless prescribed by the dentist. Also you may brush in the area unaffected by the surgery butleave the surgical areas alone for 7 days. After that you may gently clean around the area although swelling and soreness may not permit you to do so. In time, you will be able to return to proper oral hygiene care.</p> <h5>PAIN</h5> <p>Unfortunately oral surgery is usually accompanied by some degree of discomfort. You may have been given some pain medication prior to the start of your procedure. It is important to follow the instructions with pain medication as it is easier to “stay ahead of the pain rather than trying to catch up to it.” If you take the first pain pill before the local anesthetic has worn off you will be able to manage the discomfort better.</p> <h5>INFECTION</h5> <p>Unless you present with infection you usually don’t develop an infection in the first few days. Antibiotics are prescribed to either help prevent infections from developing or to treat an infection that is present. Not all procedures require an antibiotic. There is a decrease in effectiveness of birth control medication when taking antibiotics. 
226Consult your physician for advice on additional birth control measures. Slightly elevated temperature may occur for reasons other than infection. Be sure to drink lots of fluids: 1.5-2 liters /day.</p> <h5>DIET</h5> <p>Soft food is the dietary choice for the first few days. Ice cream, Jell-O, pudding, mashed potatoes, soups, pasta, or baby food are good choices. Avoid foods like nuts, popcorn, and rice as they tend to get stuck in the socket areas. Drinks like ENSURE or BOOST are good supplements as well. <b>DO NOT USE A STRAW OR DRINK FROM A BOTTLE</b> for the first 2-3 days. This can exert a force on the blood clot and slow down healing and promote bleeding. Use a spoon or a cup. After the fourth day you can progress to solid foods at you own pace. It is important to eat as you will feel better and heal faster. If you are diabetic, maintain you normal eating habits as much as possible and consult your physician regarding your insulin schedule.</p> <h5>STITCHES</h5> <p>You may have had some stitches placed. They will dissolve on their own in 5-7 days.Not all surgical sites require stitches.If a stitch comes out it is of no concern provided there is no excessive bleeding.</p> <h5>SMOKING</h5> <p>Do not smoke!It is advisable not to smoke for at least 7days.</p> <h5>SYRINGE</h5> <p>You will be given an irrigating syringe at your appointment. Fill a cup with salt water and then fill the syringe. Gently place it in the LOWER SOCKET ONLY and irrigate it 2-3 times. Do this after each meal over the next three to four weeks until the sockets close up. <b>DO NOT USE THE SYRINGE UNTIL 5 DAYS AFTER YOUR SURGERY!</b></p> <h5>REST</h5> <p>You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved.</p> <h5>SHOULD YOU BE UNABLE TO REACH ME IN AN EMERGENCY, GO TO THE NEAREST EMERGENCY ROOM</h5> <h5 style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></h5></div><fieldset id="field_12_142" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST-OPERATIVE INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_142'><div class='gchoice gchoice_12_142_1'> <input class='gfield-choice-input' name='input_142.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_142_1' /> <label for='choice_12_142_1' id='label_12_142_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_6' class='gform_page' data-js='page-field-id-21' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_22" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>PRE-SEDATION INSTRUCTIONS</h5> <h5>IF YOU DO NOT FOLLOW THE IV SEDATION INSTRUCTIONS, YOUR APPOINTMENT WILL BE <b>CANCELLED</b></h5> <p> </p><ol> <li>A: Do not eat or drink anything (EXCEPT WATER) for at least 8 hours prior to your appointment.</li> <p>
226B: You may drink water <strong>(ONLY)</strong>, at least 3 hours before the appointment.</p> <li><strong>IF YOU ARE A PATIENT WITH DIABETES (TYPE I OR TYPE II).</strong> Please consult your physician regarding your diabetes medication management prior to your dental appointment.</li> <li>If you need to take medications prescribed by your physician, TAKE IT WITH SIPS OF WATER ONLY, AT LEAST 3 HOURS prior to your appointment.</li> <li>You must have a responsible ADULT (relative or friend) escort you home in a car or taxi. You may not take public transit home!</li> <li>Please wear <strong>loose comfortable clothing preferably short sleeved (eg, t-shirt). </strong>Do not wear facial makeup or nail polish (at least one finger).</li> <li>Do not drink grapefruit juice for at least 24 hours prior to surgery.</li> </ol> <p></p> <p> Contact us prior to your appointment if there has been a change to your general health.</p> <p>IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL</p> <p>DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></p></div><fieldset id="field_12_143" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>PRE-SEDATION INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_143'><div class='gchoice gchoice_12_143_1'> <input class='gfield-choice-input' name='input_143.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_143_1' /> <label for='choice_12_143_1' id='label_12_143_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_24' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_24' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_7' class='gform_page' data-js='page-field-id-24' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_25" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST SEDATION INSTRUCTIONS</h5> <p> </p><ol> <li>Do not drive or operate hazardous equipment for 24hrs after sedation.</li> <li>A responsible person should remain with the patient for 24 hours.</li> <li>Patients must not go up or down stairs unescorted for 24hrs.</li> <li>No unattended bath or shower for 24 hrs.</li> <li>Diet is restricted by surgical procedure not the sedation.</li> <li>Drink plenty of fluids, 1.5-2 litres per day in the first three to four days.</li> <li>Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner.</li> <li>Don’t use any pillows for the first night.</li> <li>No alcohol or any other drugs with sedative properties for 24 hours or longer if drowsiness persists.</li> <li>Do not sign any important or legal documents for 24hrs.</li> <li>Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately.</li> </ol> <p></p> <p>
226Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killers are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist.</p> <p style="text-align:center"><b>DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></b></p></div><fieldset id="field_12_144" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST SEDATION INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_144'><div class='gchoice gchoice_12_144_1'> <input class='gfield-choice-input' name='input_144.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_144_1' /> <label for='choice_12_144_1' id='label_12_144_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_27' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_27' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_8' class='gform_page' data-js='page-field-id-27' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_28" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IVCS Consent</h5> <p style="text-align:center">Dr. Brian Kumer DDS<br />Consent for I.V. Conscious Sedation</p> <p>This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation.</p> <p>The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year.</p> <p>I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent.</p> <p> I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother.</p> <p>Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation.</p> <p>I have been advised of and completely understand the risks, benef
226its, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer.</p> <p> I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees.</p> <p><b>I certify that I fully understand the terms within the above consent.</b></p> </div><fieldset id="field_12_145" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>IVCS Consent</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_145'><div class='gchoice gchoice_12_145_1'> <input class='gfield-choice-input' name='input_145.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_12_145_1' /> <label for='choice_12_145_1' id='label_12_145_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_12_36' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_12_36' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_12_9' class='gform_page' data-js='page-field-id-36' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_12_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_12_165" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3>Pre-Anaesthesia Questionnaire</h3></div><div id="field_12_135" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_135'><span class='gform-field-label__text'>Patient ID *first 3 letters of your first name and the first 3 letters of your last name:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_12_135' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_37" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_37'><span class='gform-field-label__text'>Date (Please add today&#039;s date)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_12_37' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_37' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_12_37' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_12_37' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_37' aria-label='Date (Please add today' s date): choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_12_39" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datedropdown gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Date of birth:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div id='input_12_39' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_12_39_1_container'><label for='input_12_39_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month</label><select name='input_39[]' id='input_12_39_1' aria-required='true'><option value=''>Month</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option></select></div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_12_39_2_container'><label for='input_12_39_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day</label><select name='input_39[]' id='input_12_39_2' aria-required='true'><option value=''>Day</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option><option value='13'>13</option><option value='14'>14</option><option value='15'>15</option><option value='16'>16</option><option value='17'>17</option><option value='18'>18</option><option value='19'>19</option><option value='20'>20</option><option value='21'>21</option><option value='22'>22</option><option value='23'>23</option><option value='24'>24</option><option value='25'>25</option><option value='26'>26</option><option value='27'>27</option><option value='28'>28</option><option value='29'>29</option><option value='30'>30</option><option value='31'>31</option></select></div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_12_39_3_container'><label for='input_12_39_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year</label><select name='input_39[]' id='input_12_39_3' aria-required='true'><option value=''>Year</option><option value='2027'>2027</option><option value='2026'>2026</option><option value='2025'>2025</option><option value='2024'>2024</option><option value='2023'>2023</option><option value='2022'>2022</option><option value='2021'>2021</option><option value='2020'>2020</option><option value='2019'>2019</option><option value='2018'>2018</option><option value='2017'>2017</option><option value='2016'>2016</option><option value='2015'>2015</option><option value='2014'>2014</option><option value='2013'>2013</option><option value='2012'>2012</option><option value='2011'>2011</option><option value='2010'>2010</option><option value='2009'>2009</option><option value='2008'>2008</option><option value='2007'>2007</option><option value='2006'>2006</option><option value='2005'>2005</option><option value='2004'>2004</option><option value='2003'>2003</option><option value='2002'>2002</option><option value='2001'>2001</option><option value='2000'>2000</option><option value='1999'>1999</option><option value='1998'>1998</option><option value='1997'>1997</option><option value='1996'>1996</option><option value='1995'>1995</option><option value='1994'>1994</option><option value='1993'>1993</option><option value='1992'>1992</option><option value='1991'>1991</option><option value='1990'>1990</option><option value='1989'>1989</option><option value='1988'>1988</option><option value='1987'>1987</option><option value='1986'>1986</option><option value='1985'>1985</option><option value='1984'>1984</option><option value='1983'>1983</option><option value='1982'>1982</option><option value='1981'>1981</option><option value='1980'>1980</option><option value='1979'>1979</option><option value='1978'>1978</option><option value='1977'>1977</option><option value='1976'>1976</option><option value='1975'>1975</option><option value='1974'>1974</option><option value='1973'>1973</option><option value='1972'>1972</option><option value='1971'>1971</option><option value='1970'>1970</option><option value='1969'>1969</option><option value='1968'>1968</option><option value='1967'>1967</option><option value='1966'>1966</option><option value='1965'>1965</option><option value='1964'>1964</option><option value='1963'>1963</option><option value='1962'>1962</option><option value='1961'>1961</option><option value='1960'>1960</option><option value='1959'>1959</option><option value='1958'>1958</option><option value='1957'>1957</option><option value='1956'>1956</option><option value='1955'>1955</option><option value='1954'>1954</option><option value='1953'>1953</option><option value='1952'>1952</option><option value='1951'>1951</option><option value='1950'>1950</option><option value='1949'>1949</option><option value='1948'>1948</option><option value='1947'>1947</option><option value='1946'>1946</option><option value='1945'>1945</option><option value='1944'>1944</option><option value='1943'>1943</option><option value='1942'>1942</option><option value='1941'>1941</option><option value='1940'>1940</option><option value='1939'>1939</option><option value='1938'>1938</option><option value='1937'>1937</option><option value='1936'>1936</option><option value='1935'>1935</option><option value='1934'>1934</option><option value='1933'>1933</option><option value='1932'>1932</option><option value='1931'>1931</option><option value='1930'>1930</option><option value='1929'>1929</option><option value='1928'>1928</option><option value='1927'>1927</option><option value='1926'>1926</option><option value='1925'>1925</option><option value='1924'>1924</option><option value='1923'>1923</option><option value='1922'>1922</option><option value='1921'>1921</option><option value='1920'>1920</option></select></div></div></fieldset>
226<div id="field_12_40" class="gfield gfield--type-select gfield--input-type-select gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_40'><span class='gform-field-label__text'>Sex:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_12_40' class='medium gfield_select' aria-required="true" aria-invalid="false"><option value='Male'>Male</option><option value='Female'>Female</option><option value='Other'>Other</option></select></div></div><fieldset id="field_12_73" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>1. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_73'> <div class='gchoice gchoice_12_73_0'> <input class='gfield-choice-input' name='input_73' type='radio' value='Yes' id='choice_12_73_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_73_0' id='label_12_73_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_73_1'> <input class='gfield-choice-input' name='input_73' type='radio' value='No' id='choice_12_73_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_73_1' id='label_12_73_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_73_2'> <input class='gfield-choice-input' name='input_73' type='radio' value='Not Sure' id='choice_12_73_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_73_2' id='label_12_73_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_41" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>2. Do you have any health problems or concerns presently?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_41'> <div class='gchoice gchoice_12_41_0'> <input class='gfield-choice-input' name='input_41' type='radio' value='Yes' id='choice_12_41_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_41_0' id='label_12_41_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_41_1'> <input class='gfield-choice-input' name='input_41' type='radio' value='No' id='choice_12_41_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_41_1' id='label_12_41_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_41_2'> <input class='gfield-choice-input' name='input_41' type='radio' value='Not Sure' id='choice_12_41_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_41_2' id='label_12_41_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_42" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_42'><span class='gform-field-label__text'>Please explain</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_12_42' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_12_43" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>3. Has there been ANY change in your general health in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_43'> <div class='gchoice gchoice_12_43_0'> <input class='gfield-choice-input' name='input_43' type='radio' value='Yes' id='choice_12_43_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_43_0' id='label_12_43_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_43_1'> <input class='gfield-choice-input' name='input_43' type='radio' value='No' id='choice_12_43_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_43_1' id='label_12_43_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_43_2'> <input class='gfield-choice-input' name='input_43' type='radio' value='Not Sure' id='choice_12_43_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_43_2' id='label_12_43_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_45" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_45'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_12_45' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_46" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_46'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_12_46' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_230" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_230'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_230' id='input_12_230' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_231" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_231'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_12_231' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_233" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_233'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_12_233' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_232" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_232'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_232' id='input_12_232' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_47" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>4. Have you ever been in hospital for treatment?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_47'> <div class='gchoice gchoice_12_47_0'> <input class='gfield-choice-input' name='input_47' type='radio' value='Yes' id='choice_12_47_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_47_0' id='label_12_47_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_47_1'> <input class='gfield-choice-input' name='input_47' type='radio' value='No' id='choice_12_47_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_47_1' id='label_12_47_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_12_48" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_48'><span class='gform-field-label__text'>When, where and why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_12_48' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_49" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>5. Have you ever had IV Conscious Sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_49'> <div class='gchoice gchoice_12_49_0'> <input class='gfield-choice-input' name='input_49' type='radio' value='Yes' id='choice_12_49_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_49_0' id='label_12_49_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_49_1'> <input class='gfield-choice-input' name='input_49' type='radio' value='No' id='choice_12_49_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_49_1' id='label_12_49_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_49_2'> <input class='gfield-choice-input' name='input_49' type='radio' value='Not Sure' id='choice_12_49_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_49_2' id='label_12_49_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_50" class="gfield gfield--type-text gfield--in
226put-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_50'><span class='gform-field-label__text'>When, where and why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_12_50' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_51" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_51'><span class='gform-field-label__text'>Were there any problems with the Sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_12_51' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_52" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>6. Has there been any personal or family history of issues with anesthesia, IV Conscious sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_52'> <div class='gchoice gchoice_12_52_0'> <input class='gfield-choice-input' name='input_52' type='radio' value='Yes' id='choice_12_52_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_52_0' id='label_12_52_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_52_1'> <input class='gfield-choice-input' name='input_52' type='radio' value='No' id='choice_12_52_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_52_1' id='label_12_52_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_52_2'> <input class='gfield-choice-input' name='input_52' type='radio' value='Not Sure' id='choice_12_52_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_52_2' id='label_12_52_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_53" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_53'><span class='gform-field-label__text'>Please explain</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_12_53' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_12_54" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_54'><span class='gform-field-label__text'>Were any tests done?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_12_54' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_174" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>7. Do you take ANY <strong>PRESCRIPTION</strong> medications (including puffers and birth control pills)? Do you use more than one pharmacy? If yes, provide Pharmacy name + phone number of <strong>ALL </strong>pharmacies you use.</p></div><fieldset id="field_12_61" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>7. Do you take &lt;strong&gt;ANY PRESCRIPTION&lt;/strong&gt; medications (including puffers and birth control pills)?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_61'> <div class='gchoice gchoice_12_61_0'> <input class='gfield-choice-input' name='input_61' type='radio' value='Yes' id='choice_12_61_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_61_0' id='label_12_61_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_61_1'> <input class='gfield-choice-input' name='input_61' type='radio' value='No' id='choice_12_61_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_61_1' id='label_12_61_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_12_177" class="gfield gfield--type-list gfield--input-type-list gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Name of Pharmacy and Phone Number:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class="gfield_list_groups"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_177_cell1 gform-grid-col'><input aria-invalid='false' aria-required="true" aria-label='Name of Pharmacy and Phone Number:, Row 1' data-aria-label-template='Name of Pharmacy and Phone Number:, Row {0}' type='text' name='input_177[]' value='' /></div><div class='gfield_list_icons gform-grid-col'> <button type='button' aria-label='Add another row' onclick='gformAddListItem(this, 0)' class="add_list_item nitro-lazy">Add</button> <button type='button' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style="visibility:hidden" class="delete_list_item nitro-lazy">Remove</button></div></div></div></div></div></fieldset><div id="field_12_176" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>8. Do you use or take ANY <strong>NON-PRESCRIPTION</strong> medication (including herbal remedies or vitamins)?</p></div><fieldset id="field_12_64" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>8. Do you use or take &lt;strong&gt;ANY&lt;/strong&gt;
226 non-prescription remedies (including herbal remedies)?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_64'> <div class='gchoice gchoice_12_64_0'> <input class='gfield-choice-input' name='input_64' type='radio' value='Yes' id='choice_12_64_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_64_0' id='label_12_64_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_64_1'> <input class='gfield-choice-input' name='input_64' type='radio' value='No' id='choice_12_64_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_64_1' id='label_12_64_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_12_189" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_189'><span class='gform-field-label__text'>Please list:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_12_189' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_55" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>9. Are you allergic to any medications?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_55'> <div class='gchoice gchoice_12_55_0'> <input class='gfield-choice-input' name='input_55' type='radio' value='Yes' id='choice_12_55_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_55_0' id='label_12_55_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_55_1'> <input class='gfield-choice-input' name='input_55' type='radio' value='No' id='choice_12_55_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_55_1' id='label_12_55_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_55_2'> <input class='gfield-choice-input' name='input_55' type='radio' value='Not Sure' id='choice_12_55_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_55_2' id='label_12_55_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_56" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_56'><span class='gform-field-label__text'>Please list the medications that you are allergic to:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_12_56' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_191" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>What happened?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_191'> <div class='gchoice gchoice_12_191_0'> <input class='gfield-choice-input' name='input_191' type='radio' value='Rash' id='choice_12_191_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_191_0' id='label_12_191_0' class='gform-field-label gform-field-label--type-inline'>Rash</label> </div> <div class='gchoice gchoice_12_191_1'> <input class='gfield-choice-input' name='input_191' type='radio' value='Breathing problems/Wheezing' id='choice_12_191_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_191_1' id='label_12_191_1' class='gform-field-label gform-field-label--type-inline'>Breathing problems/Wheezing</label> </div> <div class='gchoice gchoice_12_191_2'> <input class='gfield-choice-input' name='input_191' type='radio' value='Swelling' id='choice_12_191_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_191_2' id='label_12_191_2' class='gform-field-label gform-field-label--type-inline'>Swelling</label> </div> <div class='gchoice gchoice_12_191_3'> <input class='gfield-choice-input' name='input_191' type='radio' value='Other' id='choice_12_191_3' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_191_3' id='label_12_191_3' class='gform-field-label gform-field-label--type-inline'>Other</label> </div></div></div></fieldset><div id="field_12_192" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_192'><span class='gform-field-label__text'>Untitled</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_12_192' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_59" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>10. Do you have any other allergies (e.g. latex)?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_59'> <div class='gchoice gchoice_12_59_0'> <input class='gfield-choice-input' name='input_59' type='radio' value='Yes' id='choice_12_59_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_59_0' id='label_12_59_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_59_1'> <input class='gfield-choice-input' name='input_59' type='radio' value='No' id='choice_12_59_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_59_1' id='label_12_59_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_12_60" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_60'><span class='gform-field-label__text'>Please list:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_12_60' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_167" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>11. Do you take any medications for Osteoporosis? (examples Risedronate, Prolia, etc.)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_167'> <div class='gchoice gchoice_12_167_0'> <input class='gfield-choice-input' name='input_167' type='radio' value='Yes' id='choice_12_167_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_167_0' id='label_12_167_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_167_1'> <input class='gfield-choice-input' name='input_167' type='radio' value='No' id='choice_12_167_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_167_1' id='label_12_167_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_167_2'> <input class='gfield-choice-input' name='input_167' type='radio' value='Not Sure' id='choice_12_167_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_167_2' id='label_12_167_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_234" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_234'><span class='gform-field-label__text'>If Prolia, date of last injection:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_12_234' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_234' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_12_234' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_12_234' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_234' aria-label='If Prolia, date of last injection:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_12_65" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>12. Do you take 81 mg ASA, daily?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_65'> <div class='gchoice gchoice_12_65_0'> <input class='gfield-choice-input' name='input_65' type='radio' value='Yes' id='choice_12_65_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_65_0' id='label_12_65_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_65_1'> <input class='gfield-choice-input' name='input_65' type='radio' value='No' id='choice_12_65_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_65_1' id='label_12_65_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_65_2'> <input class='gfield-choice-input' name='input_65' type='radio' value='Not Sure' id='choice_12_65_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_65_2' id='label_12_65_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_236" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><span style="font-size:20px;font-weight:700">DO NOT STOP YOUR DAILY ASA</span></div><fieldset id="field_12_172" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>13. Have you taken a cortisone (steroid) type drug orally in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_172'> <div class='gchoice gchoice_12_172_0'> <input class='gfield-choice-input' name='input_172' type='radio' value='Yes' id='choice_12_172_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_172_0' id='label_12_172_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_172_1'> <input class='gfield-choice-input' name='input_172' type='radio' value='No' id='choice_12_172_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_172_1' id='label_12_172_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_172_2'> <input class='gfield-choice-input' name='input_172' type='radio' value='Not Sure' id='choice_12_172_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_172_2' id='label_12_172_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_193" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_193'><span class='gform-field-label__text'>When did it start? How long were you taking it for?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_12_193' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_68" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>14. Do you or any of your relatives have a bleeding problem?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_68'> <div class='gchoice gchoice_12_68_0'> <input class='gfield-choice-input' name='input_68' type='radio' value='Yes' id='choice_12_68_0' onchange='gformToggleRadioOther( this )' />
226 <label for='choice_12_68_0' id='label_12_68_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_68_1'> <input class='gfield-choice-input' name='input_68' type='radio' value='No' id='choice_12_68_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_68_1' id='label_12_68_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_68_2'> <input class='gfield-choice-input' name='input_68' type='radio' value='Not Sure' id='choice_12_68_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_68_2' id='label_12_68_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_69" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>15. Do you have or have had any difficulty breathing through your nose?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_69'> <div class='gchoice gchoice_12_69_0'> <input class='gfield-choice-input' name='input_69' type='radio' value='Yes' id='choice_12_69_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_69_0' id='label_12_69_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_69_1'> <input class='gfield-choice-input' name='input_69' type='radio' value='No' id='choice_12_69_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_69_1' id='label_12_69_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_69_2'> <input class='gfield-choice-input' name='input_69' type='radio' value='Not Sure' id='choice_12_69_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_69_2' id='label_12_69_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_70" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>16. Do you have any nose bleeds?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_70'> <div class='gchoice gchoice_12_70_0'> <input class='gfield-choice-input' name='input_70' type='radio' value='Yes' id='choice_12_70_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_70_0' id='label_12_70_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_70_1'> <input class='gfield-choice-input' name='input_70' type='radio' value='No' id='choice_12_70_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_70_1' id='label_12_70_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_70_2'> <input class='gfield-choice-input' name='input_70' type='radio' value='Not Sure' id='choice_12_70_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_70_2' id='label_12_70_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_71" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_71'><span class='gform-field-label__text'>If so, how many per week?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_12_71' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_72" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>17. Do you have or have had any difficulty breathing while sleeping ?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_72'> <div class='gchoice gchoice_12_72_0'> <input class='gfield-choice-input' name='input_72' type='radio' value='Yes' id='choice_12_72_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_72_0' id='label_12_72_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_72_1'> <input class='gfield-choice-input' name='input_72' type='radio' value='No' id='choice_12_72_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_72_1' id='label_12_72_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_72_2'> <input class='gfield-choice-input' name='input_72' type='radio' value='Not Sure' id='choice_12_72_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_72_2' id='label_12_72_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_75" class="gfield gfield--type-html gfield--input-type-html gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>18. Do you have or have you ever had any of the following? </p></div><fieldset id="field_12_76" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart murmur:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_76'> <div class='gchoice gchoice_12_76_0'> <input class='gfield-choice-input' name='input_76' type='radio' value='Yes' id='choice_12_76_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_76_0' id='label_12_76_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_76_1'> <input class='gfield-choice-input' name='input_76' type='radio' value='No' id='choice_12_76_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_76_1' id='label_12_76_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_76_2'> <input class='gfield-choice-input' name='input_76' type='radio' value='Not Sure' id='choice_12_76_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_76_2' id='label_12_76_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_77" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart attack:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_77'> <div class='gchoice gchoice_12_77_0'> <input class='gfield-choice-input' name='input_77' type='radio' value='Yes' id='choice_12_77_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_77_0' id='label_12_77_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_77_1'> <input class='gfield-choice-input' name='input_77' type='radio' value='No' id='choice_12_77_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_77_1' id='label_12_77_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_77_2'> <input class='gfield-choice-input' name='input_77' type='radio' value='Not Sure' id='choice_12_77_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_77_2' id='label_12_77_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_79" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Chest pain or angina:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_79'> <div class='gchoice gchoice_12_79_0'> <input class='gfield-choice-input' name='input_79' type='radio' value='Yes' id='choice_12_79_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_79_0' id='label_12_79_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_79_1'> <input class='gfield-choice-input' name='input_79' type='radio' value='No' id='choice_12_79_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_79_1' id='label_12_79_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_79_2'> <input class='gfield-choice-input' name='input_79' type='radio' value='Not Sure' id='choice_12_79_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_79_2' id='label_12_79_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_80" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shortness of breath lying down:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_80'> <div class='gchoice gchoice_12_80_0'> <input class='gfield-choice-input' name='input_80' type='radio' value='Yes' id='choice_12_80_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_80_0' id='label_12_80_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_80_1'> <input class='gfield-choice-input' name='input_80' type='radio' value='No' id='choice_12_80_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_80_1' id='label_12_80_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_80_2'> <input class='gfield-choice-input' name='input_80' type='radio' value='Not Sure' id='choice_12_80_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_80_2' id='label_12_80_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_81" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Swollen ankles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_81'> <div class='gchoice gchoice_12_81_0'> <input class='gfield-choice-input' name='input_81' type='radio' value='Yes' id='choice_12_81_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_81_0' id='label_12_81_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_81_1'> <input class='gfield-choice-input' name='input_81' type='radio' value='No' id='choice_12_81_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_81_1' id='label_12_81_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_81_2'> <input class='gfield-choice-input' name='input_81' type='radio' value='Not Sure' id='choice_12_81_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_81_2' id='label_12_81_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_82" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart pacemaker/defibrillator:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_82'> <div class='gchoice gchoice_12_82_0'> <input class='gfield-choice-input' name='input_82' type='radio' value='Yes' id='choice_12_82_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_82_0' id='label_12_82_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_82_1'> <input class='gfield-choice-input' name='input_82' type='radio' value='No' id='choice_12_82_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_82_1' id='label_12_82_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_82_2'> <input class='gfield-choice-input' name='input_82' type='radio' value='Not Sure' id='choice_12_82_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_82_2' id='label_12_82_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_83" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Irregular heart beat/arrhythmia:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_83'> <div class='gchoice gchoice_12_83_0'> <input class='gfield-choice-input' name='input_83' type='radio' value='Yes' id='choice_12_83_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_83_0' id='label_12_83_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_83_1'> <input class='gfield-choice-input' name='input_83' type='radio' value='No' id='choice_12_83_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_83_1' id='label_12_83_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_83_2'> <input class='gfield-choice-input' name='input_83' type='radio' value='Not Sure' id='choice_12_83_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_83_2' id='label_12_83_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_84" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>High blood pressure:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_84'> <div class='gchoice gchoice_12_84_0'> <input class='gfield-choice-input' name='input_84' type='radio' value='Yes' id='choice_12_84_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_84_0' id='label_12_84_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_84_1'> <input class='gfield-choice-input' name='input_84' type='radio' value='No' id='choice_12_84_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_84_1' id='label_12_84_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_84_2'> <input class='gfield-choice-input' name='input_84' type='radio' value='Not Sure' id='choice_12_84_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_84_2' id='label_12_84_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_166" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shingles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_166'> <div class='gchoice gchoice_12_166_0'> <input class='gfield-choice-input' name='input_166' type='radio' value='Yes' id='choice_12_166_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_166_0' id='label_12_166_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_166_1'> <input class='gfield-choice-input' name='input_166' type='radio' value='No' id='choice_12_166_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_166_1' id='label_12_166_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_166_2'> <input class='gfield-choice-input' name='input_166' type='radio' value='Not Sure' id='choice_12_166_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_166_2' id='label_12_166_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_85" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Congenital heart disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_85'> <div class='gchoice gchoice_12_85_0'> <input class='gfield-choice-input' name='input_85' type='radio' value='Yes' id='choice_12_85_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_85_0' id='label_12_85_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_85_1'> <input class='gfield-choice-input' name='input_85' type='radio' value='No' id='choice_12_85_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_85_1' id='label_12_85_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_85_2'> <input class='gfield-choice-input' name='input_85' type='radio' value='Not Sure' id='choice_12_85_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_85_2' id='label_12_85_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_86" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Damaged/abnormal heart valves:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_86'> <div class='gchoice gchoice_12_86_0'> <input class='gfield-choice-input' name='input_86' type='radio' value='Yes' id='choice_12_86_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_86_0' id='label_12_86_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_86_1'> <input class='gfield-choice-input' name='input_86' type='radio' value='No' id='choice_12_86_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_86_1' id='label_12_86_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_86_2'> <input class='gfield-choice-input' name='input_86' type='radio' value='Not Sure' id='choice_12_86_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_86_2' id='label_12_86_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_87" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Rheumatic fever:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_87'> <div class='gchoice gchoice_12_87_0'> <input class='gfield-choice-input' name='input_87' type='radio' value='Yes' id='choice_12_87_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_87_0' id='label_12_87_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_87_1'> <input class='gfield-choice-input' name='input_87' type='radio' value='No' id='choice_12_87_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_87_1' id='label_12_87_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_87_2'> <input class='gfield-choice-input' name='input_87' type='radio' value='Not Sure' id='choice_12_87_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_87_2' id='label_12_87_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_88" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Kidney disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_88'> <div class='gchoice gchoice_12_88_0'> <input class='gfield-choice-input' name='input_88' type='radio' value='Yes' id='choice_12_88_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_88_0' id='label_12_88_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_88_1'> <input class='gfield-choice-input' name='input_88' type='radio' value='No' id='choice_12_88_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_88_1' id='label_12_88_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_88_2'> <input class='gfield-choice-input' name='input_88' type='radio' value='Not Sure' id='choice_12_88_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_88_2' id='label_12_88_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_89" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>HIV, AIDS or STD:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_89'> <div class='gchoice gchoice_12_89_0'> <input class='gfield-choice-input' name='input_89' type='radio' value='Yes' id='choice_12_89_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_89_0' id='label_12_89_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_89_1'> <input class='gfield-choice-input' name='input_89' type='radio' value='No' id='choice_12_89_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_89_1' id='label_12_89_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_89_2'> <input class='gfield-choice-input' name='input_89' type='radio' value='Not Sure' id='choice_12_89_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_89_2' id='label_12_89_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_92" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cancer / Chemotherapy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_92'> <div class='gchoice gchoice_12_92_0'> <input class='gfield-choice-input' name='input_92' type='radio' value='Yes' id='choice_12_92_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_92_0' id='label_12_92_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_92_1'> <input class='gfield-choice-input' name='input_92' type='radio' value='No' id='choice_12_92_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_92_1' id='label_12_92_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_92_2'> <input class='gfield-choice-input' name='input_92' type='radio' value='Not Sure' id='choice_12_92_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_92_2' id='label_12_92_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_93" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been screened for Sleep Apnea?:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_93'> <div class='gchoice gchoice_12_93_0'> <input class='gfield-choice-input' name='input_93' type='radio' value='Yes' id='choice_12_93_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_93_0' id='label_12_93_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_93_1'> <input class='gfield-choice-input' name='input_93' type='radio' value='No' id='choice_12_93_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_93_1' id='label_12_93_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_93_2'> <input class='gfield-choice-input' name='input_93' type='radio' value='Not Sure' id='choice_12_93_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_93_2' id='label_12_93_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_194" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been diagnosed with Sleep Apnea?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_194'> <div class='gchoice gchoice_12_194_0'> <input class='gfield-choice-input' name='input_194' type='radio' value='Yes' id='choice_12_194_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_194_0' id='label_12_194_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_194_1'> <input class='gfield-choice-input' name='input_194' type='radio' value='No' id='choice_12_194_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_194_1' id='label_12_194_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_194_2'> <input class='gfield-choice-input' name='input_194' type='radio' value='Not Sure' id='choice_12_194_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_194_2' id='label_12_194_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_94" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Asthma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_94'> <div class='gchoice gchoice_12_94_0'> <input class='gfield-choice-input' name='input_94' type='radio' value='Yes' id='choice_12_94_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_94_0' id='label_12_94_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_94_1'> <input class='gfield-choice-input' name='input_94' type='radio' value='No' id='choice_12_94_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_94_1' id='label_12_94_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_94_2'> <input class='gfield-choice-input' name='input_94' type='radio' value='Not Sure' id='choice_12_94_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_94_2' id='label_12_94_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_95" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Emphysema / Bronchitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_95'> <div class='gchoice gchoice_12_95_0'> <input class='gfield-choice-input' name='input_95' type='radio' value='Yes' id='choice_12_95_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_95_0' id='label_12_95_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_95_1'> <input class='gfield-choice-input' name='input_95' type='radio' value='No' id='choice_12_95_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_95_1' id='label_12_95_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_95_2'> <input class='gfield-choice-input' name='input_95' type='radio' value='Not Sure' id='choice_12_95_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_95_2' id='label_12_95_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_96" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cystic fibrosis / Tuberculosis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_96'> <div class='gchoice gchoice_12_96_0'> <input class='gfield-choice-input' name='input_96' type='radio' value='Yes' id='choice_12_96_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_96_0' id='label_12_96_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_96_1'> <input class='gfield-choice-input' name='input_96' type='radio' value='No' id='choice_12_96_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_96_1' id='label_12_96_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_96_2'> <input class='gfield-choice-input' name='input_96' type='radio' value='Not Sure' id='choice_12_96_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_96_2' id='label_12_96_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_97" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Epilepsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_97'> <div class='gchoice gchoice_12_97_0'> <input class='gfield-choice-input' name='input_97' type='radio' value='Yes' id='choice_12_97_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_97_0' id='label_12_97_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_97_1'> <input class='gfield-choice-input' name='input_97' type='radio' value='No' id='choice_12_97_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_97_1' id='label_12_97_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_97_2'> <input class='gfield-choice-input' name='input_97' type='radio' value='Not Sure' id='choice_12_97_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_97_2' id='label_12_97_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_98" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stroke:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_98'> <div class='gchoice gchoice_12_98_0'> <input class='gfield-choice-input' name='input_98' type='radio' value='Yes' id='choice_12_98_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_98_0' id='label_12_98_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_98_1'> <input class='gfield-choice-input' name='input_98' type='radio' value='No' id='choice_12_98_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_98_1' id='label_12_98_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_98_2'> <input class='gfield-choice-input' name='input_98' type='radio' value='Not Sure' id='choice_12_98_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_98_2' id='label_12_98_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_99" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Fainting spells, dizziness:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_99'> <div class='gchoice gchoice_12_99_0'> <input class='gfield-choice-input' name='input_99' type='radio' value='Yes' id='choice_12_99_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_99_0' id='label_12_99_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_99_1'> <input class='gfield-choice-input' name='input_99' type='radio' value='No' id='choice_12_99_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_99_1' id='label_12_99_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_99_2'> <input class='gfield-choice-input' name='input_99' type='radio' value='Not Sure' id='choice_12_99_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_99_2' id='label_12_99_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_100" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Diabetes:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_100'> <div class='gchoice gchoice_12_100_0'> <input class='gfield-choice-input' name='input_100' type='radio' value='Yes' id='choice_12_100_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_100_0' id='label_12_100_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_100_1'> <input class='gfield-choice-input' name='input_100' type='radio' value='No' id='choice_12_100_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_100_1' id='label_12_100_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_100_2'> <input class='gfield-choice-input' name='input_100' type='radio' value='Not Sure' id='choice_12_100_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_100_2' id='label_12_100_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_101" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Thyroid Disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_101'> <div class='gchoice gchoice_12_101_0'> <input class='gfield-choice-input' name='input_101' type='radio' value='Yes' id='choice_12_101_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_101_0' id='label_12_101_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_101_1'> <input class='gfield-choice-input' name='input_101' type='radio' value='No' id='choice_12_101_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_101_1' id='label_12_101_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_101_2'> <input class='gfield-choice-input' name='input_101' type='radio' value='Not Sure' id='choice_12_101_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_101_2' id='label_12_101_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_102" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Adrenal gland disorder:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_102'> <div class='gchoice gchoice_12_102_0'> <input class='gfield-choice-input' name='input_102' type='radio' value='Yes' id='choice_12_102_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_102_0' id='label_12_102_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_102_1'> <input class='gfield-choice-input' name='input_102' type='radio' value='No' id='choice_12_102_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_102_1' id='label_12_102_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_102_2'> <input class='gfield-choice-input' name='input_102' type='radio' value='Not Sure' id='choice_12_102_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_102_2' id='label_12_102_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_103" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Hepatitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_103'> <div class='gchoice gchoice_12_103_0'> <input class='gfield-choice-input' name='input_103' type='radio' value='Yes' id='choice_12_103_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_103_0' id='label_12_103_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_103_1'> <input class='gfield-choice-input' name='input_103' type='radio' value='No' id='choice_12_103_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_103_1' id='label_12_103_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_103_2'> <input class='gfield-choice-input' name='input_103' type='radio' value='Not Sure' id='choice_12_103_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_103_2' id='label_12_103_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_104" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Liver disease / Jaundice:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_104'> <div class='gchoice gchoice_12_104_0'> <input class='gfield-choice-input' name='input_104' type='radio' value='Yes' id='choice_12_104_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_104_0' id='label_12_104_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_104_1'> <input class='gfield-choice-input' name='input_104' type='radio' value='No' id='choice_12_104_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_104_1' id='label_12_104_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_104_2'> <input class='gfield-choice-input' name='input_104' type='radio' value='Not Sure' id='choice_12_104_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_104_2' id='label_12_104_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_105" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Anemia (including sickle cell):</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_105'> <div class='gchoice gchoice_12_105_0'> <input class='gfield-choice-input' name='input_105' type='radio' value='Yes' id='choice_12_105_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_105_0' id='label_12_105_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_105_1'> <input class='gfield-choice-input' name='input_105' type='radio' value='No' id='choice_12_105_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_105_1' id='label_12_105_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_105_2'> <input class='gfield-choice-input' name='input_105' type='radio' value='Not Sure' id='choice_12_105_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_105_2' id='label_12_105_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_106" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Blood disorders/transfusions:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_106'> <div class='gchoice gchoice_12_106_0'> <input class='gfield-choice-input' name='input_106' type='radio' value='Yes' id='choice_12_106_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_106_0' id='label_12_106_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_106_1'> <input class='gfield-choice-input' name='input_106' type='radio' value='No' id='choice_12_106_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_106_1' id='label_12_106_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_106_2'> <input class='gfield-choice-input' name='input_106' type='radio' value='Not Sure' id='choice_12_106_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_106_2' id='label_12_106_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_107" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bleeding (Coagulation) disorders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_107'> <div class='gchoice gchoice_12_107_0'> <input class='gfield-choice-input' name='input_107' type='radio' value='Yes' id='choice_12_107_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_107_0' id='label_12_107_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_107_1'> <input class='gfield-choice-input' name='input_107' type='radio' value='No' id='choice_12_107_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_107_1' id='label_12_107_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_107_2'> <input class='gfield-choice-input' name='input_107' type='radio' value='Not Sure' id='choice_12_107_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_107_2' id='label_12_107_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_108" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stomach ulcers/ Acid Reflux:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_108'> <div class='gchoice gchoice_12_108_0'> <input class='gfield-choice-input' name='input_108' type='radio' value='Yes' id='choice_12_108_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_108_0' id='label_12_108_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_108_1'> <input class='gfield-choice-input' name='input_108' type='radio' value='No' id='choice_12_108_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_108_1' id='label_12_108_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_108_2'> <input class='gfield-choice-input' name='input_108' type='radio' value='Not Sure' id='choice_12_108_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_108_2' id='label_12_108_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_109" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bone, joint, or muscle problems:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_109'> <div class='gchoice gchoice_12_109_0'> <input class='gfield-choice-input' name='input_109' type='radio' value='Yes' id='choice_12_109_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_109_0' id='label_12_109_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_109_1'> <input class='gfield-choice-input' name='input_109' type='radio' value='No' id='choice_12_109_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_109_1' id='label_12_109_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_109_2'> <input class='gfield-choice-input' name='input_109' type='radio' value='Not Sure' id='choice_12_109_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_109_2' id='label_12_109_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_110" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Artificial joints - hips, knees, shoulders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_110'> <div class='gchoice gchoice_12_110_0'> <input class='gfield-choice-input' name='input_110' type='radio' value='Yes' id='choice_12_110_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_110_0' id='label_12_110_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_110_1'> <input class='gfield-choice-input' name='input_110' type='radio' value='No' id='choice_12_110_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_110_1' id='label_12_110_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_110_2'> <input class='gfield-choice-input' name='input_110' type='radio' value='Not Sure' id='choice_12_110_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_110_2' id='label_12_110_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_183" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_183'><span class='gform-field-label__text'>Date of replacement:</span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_12_183' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_183' value='' aria-invalid="false" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_12_183' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_12_183' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_183' aria-label='Date of replacement:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_12_111" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Arthritis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_111'> <div class='gchoice gchoice_12_111_0'> <input class='gfield-choice-input' name='input_111' type='radio' value='Yes' id='choice_12_111_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_111_0' id='label_12_111_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_111_1'> <input class='gfield-choice-input' name='input_111' type='radio' value='No' id='choice_12_111_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_111_1' id='label_12_111_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_111_2'> <input class='gfield-choice-input' name='input_111' type='radio' value='Not Sure' id='choice_12_111_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_111_2' id='label_12_111_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_112" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Depression / anxiety:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_112'> <div class='gchoice gchoice_12_112_0'> <input class='gfield-choice-input' name='input_112' type='radio' value='Yes' id='choice_12_112_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_112_0' id='label_12_112_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_112_1'> <input class='gfield-choice-input' name='input_112' type='radio' value='No' id='choice_12_112_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_112_1' id='label_12_112_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_112_2'> <input class='gfield-choice-input' name='input_112' type='radio' value='Not Sure' id='choice_12_112_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_112_2' id='label_12_112_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_113" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Vision problems / glaucoma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_113'> <div class='gchoice gchoice_12_113_0'> <input class='gfield-choice-input' name='input_113' type='radio' value='Yes' id='choice_12_113_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_113_0' id='label_12_113_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_113_1'> <input class='gfield-choice-input' name='input_113' type='radio' value='No' id='choice_12_113_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_113_1' id='label_12_113_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_113_2'> <input class='gfield-choice-input' name='input_113' type='radio' value='Not Sure' id='choice_12_113_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_113_2' id='label_12_113_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_114" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>People with intellectual/cognitive disabilities:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_114'> <div class='gchoice gchoice_12_114_0'> <input class='gfield-choice-input' name='input_114' type='radio' value='Yes' id='choice_12_114_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_114_0' id='label_12_114_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_114_1'> <input class='gfield-choice-input' name='input_114' type='radio' value='No' id='choice_12_114_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_114_1' id='label_12_114_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_114_2'> <input class='gfield-choice-input' name='input_114' type='radio' value='Not Sure' id='choice_12_114_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_114_2' id='label_12_114_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_115" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cerebral palsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_115'> <div class='gchoice gchoice_12_115_0'> <input class='gfield-choice-input' name='input_115' type='radio' value='Yes' id='choice_12_115_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_115_0' id='label_12_115_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_115_1'> <input class='gfield-choice-input' name='input_115' type='radio' value='No' id='choice_12_115_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_115_1' id='label_12_115_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_115_2'> <input class='gfield-choice-input' name='input_115' type='radio' value='Not Sure' id='choice_12_115_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_115_2' id='label_12_115_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_116" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Autism or Down&#039;s syndrome:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_116'> <div class='gchoice gchoice_12_116_0'> <input class='gfield-choice-input' name='input_116' type='radio' value='Yes' id='choice_12_116_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_116_0' id='label_12_116_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_116_1'> <input class='gfield-choice-input' name='input_116' type='radio' value='No' id='choice_12_116_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_116_1' id='label_12_116_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_116_2'> <input class='gfield-choice-input' name='input_116' type='radio' value='Not Sure' id='choice_12_116_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_116_2' id='label_12_116_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_117" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_117'> <div class='gchoice gchoice_12_117_0'> <input class='gfield-choice-input' name='input_117' type='radio' value='Yes' id='choice_12_117_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_117_0' id='label_12_117_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_117_1'> <input class='gfield-choice-input' name='input_117' type='radio' value='No' id='choice_12_117_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_117_1' id='label_12_117_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_117_2'> <input class='gfield-choice-input' name='input_117' type='radio' value='Not Sure' id='choice_12_117_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_117_2' id='label_12_117_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_118" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you a nursing mother?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_118'> <div class='gchoice gchoice_12_118_0'> <input class='gfield-choice-input' name='input_118' type='radio' value='Yes' id='choice_12_118_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_118_0' id='label_12_118_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_118_1'> <input class='gfield-choice-input' name='input_118' type='radio' value='No' id='choice_12_118_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_118_1' id='label_12_118_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_118_2'> <input class='gfield-choice-input' name='input_118' type='radio' value='Not Sure' id='choice_12_118_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_118_2' id='label_12_118_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_119" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Any problems with menstruation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_119'> <div class='gchoice gchoice_12_119_0'> <input class='gfield-choice-input' name='input_119' type='radio' value='Yes' id='choice_12_119_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_119_0' id='label_12_119_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_119_1'> <input class='gfield-choice-input' name='input_119' type='radio' value='No' id='choice_12_119_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_119_1' id='label_12_119_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_119_2'> <input class='gfield-choice-input' name='input_119' type='radio' value='Not Sure' id='choice_12_119_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_119_2' id='label_12_119_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_120" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>19. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_120'> <div class='gchoice gchoice_12_120_0'> <input class='gfield-choice-input' name='input_120' type='radio' value='Yes' id='choice_12_120_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_120_0' id='label_12_120_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_120_1'> <input class='gfield-choice-input' name='input_120' type='radio' value='No' id='choice_12_120_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_120_1' id='label_12_120_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_120_2'> <input class='gfield-choice-input' name='input_120' type='radio' value='Not Sure' id='choice_12_120_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_120_2' id='label_12_120_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_121" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>20. Do you have any problems opening your mouth wide or moving your neck fully?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_121'>
226 <div class='gchoice gchoice_12_121_0'> <input class='gfield-choice-input' name='input_121' type='radio' value='Yes' id='choice_12_121_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_121_0' id='label_12_121_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_121_1'> <input class='gfield-choice-input' name='input_121' type='radio' value='No' id='choice_12_121_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_121_1' id='label_12_121_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_121_2'> <input class='gfield-choice-input' name='input_121' type='radio' value='Not Sure' id='choice_12_121_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_121_2' id='label_12_121_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_122" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>21. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_122'> <div class='gchoice gchoice_12_122_0'> <input class='gfield-choice-input' name='input_122' type='radio' value='Yes' id='choice_12_122_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_122_0' id='label_12_122_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_122_1'> <input class='gfield-choice-input' name='input_122' type='radio' value='No' id='choice_12_122_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_122_1' id='label_12_122_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_122_2'> <input class='gfield-choice-input' name='input_122' type='radio' value='Not Sure' id='choice_12_122_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_122_2' id='label_12_122_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_184" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_184'><span class='gform-field-label__text'>When?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_12_184' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_184' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_12_184' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_12_184' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_184' aria-label='When?: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><div id="field_12_185" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_185'><span class='gform-field-label__text'>Where?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_12_185' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_12_235" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_235'><span class='gform-field-label__text'>Name of oncologist:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_12_235' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_123" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>22. Do you smoke?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_123'> <div class='gchoice gchoice_12_123_0'> <input class='gfield-choice-input' name='input_123' type='radio' value='Yes' id='choice_12_123_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_123_0' id='label_12_123_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_123_1'> <input class='gfield-choice-input' name='input_123' type='radio' value='No' id='choice_12_123_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_123_1' id='label_12_123_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_123_2'> <input class='gfield-choice-input' name='input_123' type='radio' value='Not Sure' id='choice_12_123_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_123_2' id='label_12_123_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_125" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_125'><span class='gform-field-label__text'>If so how much?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_12_125' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_124" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>23. Do you drink more than 5 alcoholic beverages per week? Number/week</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_124'> <div class='gchoice gchoice_12_124_0'> <input class='gfield-choice-input' name='input_124' type='radio' value='Yes' id='choice_12_124_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_124_0' id='label_12_124_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_124_1'> <input class='gfield-choice-input' name='input_124' type='radio' value='No' id='choice_12_124_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_124_1' id='label_12_124_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_124_2'> <input class='gfield-choice-input' name='input_124' type='radio' value='Not Sure' id='choice_12_124_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_124_2' id='label_12_124_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_126" class="gfield gfield--type-text gfield--in
226put-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_12_126'><span class='gform-field-label__text'>Number/week</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_12_126' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_12_127" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>24. Do you have a history of alcoholism or drug dependence or substance abuse?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_127'> <div class='gchoice gchoice_12_127_0'> <input class='gfield-choice-input' name='input_127' type='radio' value='Yes' id='choice_12_127_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_127_0' id='label_12_127_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_127_1'> <input class='gfield-choice-input' name='input_127' type='radio' value='No' id='choice_12_127_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_127_1' id='label_12_127_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_127_2'> <input class='gfield-choice-input' name='input_127' type='radio' value='Not Sure' id='choice_12_127_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_127_2' id='label_12_127_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_128" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>25. Have you taken any recreational drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, crystal meth, codeine, oxycodone or other drugs?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_128'> <div class='gchoice gchoice_12_128_0'> <input class='gfield-choice-input' name='input_128' type='radio' value='Yes' id='choice_12_128_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_128_0' id='label_12_128_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_128_1'> <input class='gfield-choice-input' name='input_128' type='radio' value='No' id='choice_12_128_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_128_1' id='label_12_128_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_128_2'> <input class='gfield-choice-input' name='input_128' type='radio' value='Not Sure' id='choice_12_128_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_128_2' id='label_12_128_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_12_129" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>26. Do you have a history of alcoholism or substance abuse?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_129'> <div class='gchoice gchoice_12_129_0'> <input class='gfield-choice-input' name='input_129' type='radio' value='Yes' id='choice_12_129_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_129_0' id='label_12_129_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_12_129_1'> <input class='gfield-choice-input' name='input_129' type='radio' value='No' id='choice_12_129_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_129_1' id='label_12_129_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_12_129_2'> <input class='gfield-choice-input' name='input_129' type='radio' value='Not Sure' id='choice_12_129_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_12_129_2' id='label_12_129_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_12_130" class="gfield gfield--type-textarea gfield--in
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style='font-family:&quot;Noteworthy&quot;,&quot;Segoe Print&quot;,cursive;color:#000' aria-label='Your Name, Print style'>Your Name</li></ul></div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center'><button type='button' id='input_12_181_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Text Signature' aria-label='Text Signature'></button><button type='button' id='input_12_181_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Draw Signature' aria-label='Draw Signature'></button><button type='button' id='input_12_181_resetbutton' 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id='gform_wrapper_11' style='display:none'><div id='gf_11' class='gform_anchor' tabindex='-1'></div> <div class='gform_heading'> <p class='gform_required_legend'>&quot;
226<span class="gfield_required gfield_required_asterisk">*</span>&quot; indicates required fields</p> </div><form method='post' enctype='multipart/form-data' id='gform_11' action='/locations/#gf_11' data-formid='11' novalidate> <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper' data-start-at-zero='1'> <p class="gf_progressbar_title">Step <span class='gf_step_current_page'>1</span> of <span class='gf_step_page_count'>5</span><span class='gf_step_page_name'></span> </p> <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'> <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%'><span>0%</span></div> </div></div> <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-0'> <div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_11_1" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>IMPLANT SURGERY</h5> <h5>INFORMATION AND CONSENT FORM</h5> <p></p><ol> <li>I have been informed of and I understand the purpose and nature of the implant surgery procedure. I understand what is necessary to accomplish the placement of the implant under the gum or in the bone.</li> <li>My doctor has carefully examined my mouth and explained alternatives to this treatment have been explained to me. I have either tried or have considered these options and have concluded that an implant is my treatment of choice to secure the tooth or denture to be replaced.</li> <li>I have further been informed of the possible risks and complications involved with surgery, drugs (allergic or adverse reactions) and anesthesia. Such complications include pain, swelling, infection, bruising. Numbness of the lip, tongue, chin, cheek or teeth may occur. The exact duration may not be determinable and may be irreversible. Other possible risks are injury to other teeth, bone fractures, sinus perforation, delayed healing, rejection of the implant.</li> <li>It has been explained to me that in some instances implants fail and must be removed. The success rate of dental implant surgery is very high but dentistry is not an exact science and no guarantee or assurance as to the outcome of the result of treatment can be made.</li> <li>I understand that if nothing is done any of the following could occur: loss of bone and/or gum tissue, inflammation of the gums, infection, loose teeth, loss of teeth, and the occurrence or reoccurrence of Temporomandibular (jaw) joint symptoms</li> <li>I understand that excessive smoking, alcohol, or sugar may affect healing and may limit the success of the implant. I agree to follow my doctors home care instructions. I agree to report to my doctor for regular examinations as instructed.</li> <li> To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, reported any bleeding disorders or any other condition related to my health</li> <li>I consent to the photographing filming videotaping of the procedure to be performed provided my identity is not revealed.</li> <li>I request and authorize the dental services for me, including implants and other surgical procedures as deemed necessary to accomplish the placement of the implants. I fully understand that during and following the procedure conditions may become apparent that warrant additional or alternative treatments pertinent o the success of the comprehensive treatment. I also approve any modification in the design or materials if it is felt to be in my best interest.</li> <li>The fees for this treatment plan and the payment plan have been explained to me and I have approved them.</li></ol><p></p></div><fieldset id="field_11_64" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFORMATION AND CONSENT FORM</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_64'><div class='gchoice gchoice_11_64_1'> <input class='gfield-choice-input' name='input_64.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_11_64_1' /> <label for='choice_11_64_1' id='label_11_64_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_11_168' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_11_2' class='gform_page' data-js='page-field-id-168' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_11_10" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h3></div><div id="field_11_129" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_11_83" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_11_130" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_130'><div class='gchoice gchoice_11_130_1'> <input class='gfield-choice-input' name='input_130.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_11_130_1' /> <label for='choice_11_130_1' id='label_11_130_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_11_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_11_6' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_11_3' class='gform_page' data-js='page-field-id-6' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_below description_below validation_below'>
226<div id="field_11_4" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>Ontario’s Narcotics Strategy</h5> <h5>List Of Approved Forms Of Identification</h5> <p></p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul> <p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li> Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>oyal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_11_65" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_65'><div class='gchoice gchoice_11_65_1'> <input class='gfield-choice-input' name='input_65.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_11_65_1' /> <label for='choice_11_65_1' id='label_11_65_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_11_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_11_9' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_11_4' class='gform_page' data-js='page-field-id-9' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_11_7" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST OP FOR DENTAL IMPLANTS</h5> <p></p><ol> <li><b>Smoking:</b> Do not smoke. Patients who smoke will experience delayed healing and greater discomfort and are at higher risk for infection. In addition smoking will compromise your result.</li> <li><b>Medication:</b> It is important to follow the instructions written on your prescription. If you experience any unfavourable reactions such as nausea, vomiting, diarrhea, rash, etc. call the doctor.</li> <li><b>Rest:</b> Do not plan on any activities for the remainder of the day. Avoid any strenuous activity for 1 week following surgery.</li> <li><b>Pain:</b> Some discomfort is expected once the anesthetic wears off. If you were prescribed post-operative pain medication, begin taking it before the anesthetic wears off to minimize discomfort. Ibuprofen is an effective pain medication and also reduces swelling. It can be taken for the first 3-4 days on a continuous basis (4 times per day) with a maximum dose of 3 grams per day. You may take Ibuprofen in addition to and at the same time as a prescribed narcotic such as Tylenol #2 or #3.</li> <li><b>Swelling:</b> Some swelling may occur the day after surgery and will generally persist for 24-36 hours, then diminish.Swelling can be minimized by placing an ice pack on the outside of the face over the surgical site alternating on and off in 10 minute intervals. You should do this forthe 24 hours following your surgery.</li> <li><b>Bleeding:</b> There should be no outright bleeding after surgery, though a slight pinkish colour to your saliva is common. If bleeding occurs, place a moistened non herbal tea bag over the area and apply gentle pressure. Continue this for 20 minutes. If bleeding persists call the doctor.</li> <li> <b>Rinsing:</b> Following your surgery you should rinse with warm salt water for the next 24 hours. Do not brush or floss or water pik in the area involved in the surgery. If you have been prescribed mouthwash use it twice daily until the stiches are removed. Make sure there is no toothpaste in your mouth when rinsing.</li> <li><b>Diet:</b> It is important to maintain a normal healthy diet. Do not drink any hot drinks for the first 24 hours. The 4 days following surgery eat soft foods (oatmeal, cottage cheese, eggs, avocado, fruit and vegetable juices) Try to do 
226your chewing on the opposite site of your mouth from where the surgery took place. Avoid any coarse foods such as seeds, nuts, chips, popcorn etc. . . . It may be necessary to maintain a liquid diet for a few days. Increase your fluid intake during this time. Avoid using a straw for 4 days.</li> </ol><p></p> <h5 style="text-align:center">Dr. Brian Kumer<br /><a href="tel:+4166050008">(416) 605-0008</a> </h5></div><fieldset id="field_11_66" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST OP FOR DENTAL IMPLANTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_66'><div class='gchoice gchoice_11_66_1'> <input class='gfield-choice-input' name='input_66.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_11_66_1' /> <label for='choice_11_66_1' id='label_11_66_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_11_16' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_11_16' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_11_5' class='gform_page' data-js='page-field-id-16' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_11_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_11_17" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>MEDICAL HISTORY</h5> <p> The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. </p></div><div id="field_11_18" class="gfield gfield--type-select gfield--input-type-select gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_18'><span class='gform-field-label__text'>Sex:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_11_18' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='Male'>Male</option><option value='Female'>Female</option><option value='Not Sure'>Not Sure</option></select></div></div><div id="field_11_19" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_19'><span class='gform-field-label__text'>Date (Please add today&#039;s date)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_11_19' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_19' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_11_19' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_11_19' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_19' aria-label='Date (Please add today' s date): choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><div id="field_11_20" class="gfield gfield--type-text gfield--in
226put-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_20'><span class='gform-field-label__text'>Patient ID *first 3 letters of your first name and the first 3 letters of your last name:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_11_20' type='text' value='' class='large' placeholder='aaaaaa' aria-required="true" aria-invalid="false" data-mask="aaaaaa" /></div></div><fieldset id="field_11_21" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Date of birth:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div id='input_11_21' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_11_21_1_container'><label for='input_11_21_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month</label><select name='input_21[]' id='input_11_21_1' aria-required='true'><option value=''>Month</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option></select></div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_11_21_2_container'><label for='input_11_21_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day</label><select name='input_21[]' id='input_11_21_2' aria-required='true'><option value=''>Day</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option><option value='13'>13</option><option value='14'>14</option><option value='15'>15</option><option value='16'>16</option><option value='17'>17</option><option value='18'>18</option><option value='19'>19</option><option value='20'>20</option><option value='21'>21</option><option value='22'>22</option><option value='23'>23</option><option value='24'>24</option><option value='25'>25</option><option value='26'>26</option><option value='27'>27</option><option value='28'>28</option><option value='29'>29</option><option value='30'>30</option><option value='31'>31</option></select></div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_11_21_3_container'><label for='input_11_21_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year</label><select name='input_21[]' id='input_11_21_3' aria-required='true'><option value=''>Year</option><option value='2027'>2027</option><option value='2026'>2026</option><option value='2025'>2025</option><option value='2024'>2024</option><option value='2023'>2023</option><option value='2022'>2022</option><option value='2021'>2021</option><option value='2020'>2020</option><option value='2019'>2019</option><option value='2018'>2018</option><option value='2017'>2017</option><option value='2016'>2016</option><option value='2015'>2015</option><option value='2014'>2014</option><option value='2013'>2013</option><option value='2012'>2012</option><option value='2011'>2011</option><option value='2010'>2010</option><option value='2009'>2009</option><option value='2008'>2008</option><option value='2007'>2007</option><option value='2006'>2006</option><option value='2005'>2005</option><option value='2004'>2004</option><option value='2003'>2003</option><option value='2002'>2002</option><option value='2001'>2001</option><option value='2000'>2000</option><option value='1999'>1999</option><option value='1998'>1998</option><option value='1997'>1997</option><option value='1996'>1996</option><option value='1995'>1995</option><option value='1994'>1994</option><option value='1993'>1993</option><option value='1992'>1992</option><option value='1991'>1991</option><option value='1990'>1990</option><option value='1989'>1989</option><option value='1988'>1988</option><option value='1987'>1987</option><option value='1986'>1986</option><option value='1985'>1985</option><option value='1984'>1984</option><option value='1983'>1983</option><option value='1982'>1982</option><option value='1981'>1981</option><option value='1980'>1980</option><option value='1979'>1979</option><option value='1978'>1978</option><option value='1977'>1977</option><option value='1976'>1976</option><option value='1975'>1975</option><option value='1974'>1974</option><option value='1973'>1973</option><option value='1972'>1972</option><option value='1971'>1971</option><option value='1970'>1970</option><option value='1969'>1969</option><option value='1968'>1968</option><option value='1967'>1967</option><option value='1966'>1966</option><option value='1965'>1965</option><option value='1964'>1964</option><option value='1963'>1963</option><option value='1962'>1962</option><option value='1961'>1961</option><option value='1960'>1960</option><option value='1959'>1959</option><option value='1958'>1958</option><option value='1957'>1957</option><option value='1956'>1956</option><option value='1955'>1955</option><option value='1954'>1954</option><option value='1953'>1953</option><option value='1952'>1952</option><option value='1951'>1951</option><option value='1950'>1950</option><option value='1949'>1949</option><option value='1948'>1948</option><option value='1947'>1947</option><option value='1946'>1946</option><option value='1945'>1945</option><option value='1944'>1944</option><option value='1943'>1943</option><option value='1942'>1942</option><option value='1941'>1941</option><option value='1940'>1940</option><option value='1939'>1939</option><option value='1938'>1938</option><option value='1937'>1937</option><option value='1936'>1936</option><option value='1935'>1935</option><option value='1934'>1934</option><option value='1933'>1933</option><option value='1932'>1932</option><option value='1931'>1931</option><option value='1930'>1930</option><option value='1929'>1929</option><option value='1928'>1928</option><option value='1927'>1927</option><option value='1926'>1926</option><option value='1925'>1925</option><option value='1924'>1924</option><option value='1923'>1923</option><option value='1922'>1922</option><option value='1921'>1921</option><option value='1920'>1920</option></select></div></div></fieldset><div id="field_11_132" class="gfield gfield--type-text gfield--in
226put-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_132'><span class='gform-field-label__text'>What&#039;s your weight (lbs)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_11_132' type='text' value='' class='medium' placeholder='999' aria-required="true" aria-invalid="false" data-mask="999" /></div></div><div id="field_11_147" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>What's your height?</p></div><div id="field_11_148" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_148'><span class='gform-field-label__text'>Feet</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_148' id='input_11_148' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option></select></div></div><div id="field_11_149" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_149'><span class='gform-field-label__text'>Inches</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_149' id='input_11_149' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11.5'>11.5</option></select></div></div><fieldset id="field_11_28" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>1. Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_28'> <div class='gchoice gchoice_11_28_0'> <input class='gfield-choice-input' name='input_28' type='radio' value='Yes' id='choice_11_28_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_28_0' id='label_11_28_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_28_1'> <input class='gfield-choice-input' name='input_28' type='radio' value='No' id='choice_11_28_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_28_1' id='label_11_28_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_28_2'> <input class='gfield-choice-input' name='input_28' type='radio' value='Not Sure' id='choice_11_28_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_28_2' id='label_11_28_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_23" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_23'><span class='gform-field-label__text'>Explain:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_11_23' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_11_62" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_62'><span class='gform-field-label__text'>2. When was your last medical checkup?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_11_62' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_11_152" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>3. Has there been any change in your general health in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_152'> <div class='gchoice gchoice_11_152_0'> <input class='gfield-choice-input' name='input_152' type='radio' value='Yes' id='choice_11_152_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_152_0' id='label_11_152_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_152_1'> <input class='gfield-choice-input' name='input_152' type='radio' value='No' id='choice_11_152_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_152_1' id='label_11_152_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_152_2'> <input class='gfield-choice-input' name='input_152' type='radio' value='Not Sure' id='choice_11_152_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_152_2' id='label_11_152_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_161" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_161'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_11_161' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_162" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_162'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_11_162' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_171" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_171'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_11_171' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_170" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_170'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_11_170' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_173" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_173'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_173' id='input_11_173' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_172" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_172'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_11_172' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_11_30" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Has there been any personal or family history of issues with anesthesia, IV Conscious sedation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_30'> <div class='gchoice gchoice_11_30_0'> <input class='gfield-choice-input' name='input_30' type='radio' value='Yes' id='choice_11_30_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_30_0' id='label_11_30_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_30_1'> <input class='gfield-choice-input' name='input_30' type='radio' value='No' id='choice_11_30_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_30_1' id='label_11_30_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_30_2'> <input class='gfield-choice-input' name='input_30' type='radio' value='Not Sure' id='choice_11_30_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_30_2' id='label_11_30_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_141" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>4. Do you take ANY <strong>PRESCRIPTION</strong>medications (including puffers and birth control pills)? Do you use more than one pharmacy? If yes, provide Pharmacy name + phone number of <strong>ALL </strong> pharmacies you use.</p></div><fieldset id="field_11_39" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>4. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)? If yes provide Pharmacy name + number of ALL pharmacies you use.</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_39'> <div class='gchoice gchoice_11_39_0'> <input class='gfield-choice-input' name='input_39' type='radio' value='Yes' id='choice_11_39_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_39_0' id='label_11_39_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_39_1'> <input class='gfield-choice-input' name='input_39' type='radio' value='No' id='choice_11_39_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_39_1' id='label_11_39_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_11_145" class="gfield gfield--type-list gfield--input-type-list gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Name of Pharmacy &amp; Phone Number:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class="gfield_list_groups"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_145_cell1 gform-grid-col'><input aria-invalid='false' aria-required="true" aria-label='Name of Pharmacy &amp; Phone Number:, Row 1' data-aria-label-template='Name of Pharmacy &amp; Phone Number:, Row {0}' type='text' name='input_145[]' value='' /></div><div class='gfield_list_icons gform-grid-col'> <button type='button' aria-label='Add another row' onclick='gformAddListItem(this, 0)' class="add_list_item nitro-lazy">Add</button> <button type='button' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style="visibility:hidden" class="delete_list_item nitro-lazy">Remove</button></div></div></div></div></div></fieldset><div id="field_11_142" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible">5. Do you use or take ANY <strong>NON-PRESCRIPTION</strong> medication (including herbal remedies or vitamins)?</div><fieldset id="field_11_31" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>5. Are you taking any non-prescription drugs or herbal supplements of any kind?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_31'> <div class='gchoice gchoice_11_31_0'> <input class='gfield-choice-input' name='input_31' type='radio' value='Yes' id='choice_11_31_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_31_0' id='label_11_31_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_31_1'> <input class='gfield-choice-input' name='input_31' type='radio' value='No' id='choice_11_31_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_31_1' id='label_11_31_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_11_163" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_163'><span class='gform-field-label__text'>Please list:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_11_163' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_11_34" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>6. Do you have any allergies to medications?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_34'> <div class='gchoice gchoice_11_34_0'> <input class='gfield-choice-input' name='input_34' type='radio' value='Yes' id='choice_11_34_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_34_0' id='label_11_34_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_34_1'> <input class='gfield-choice-input' name='input_34' type='radio' value='No' id='choice_11_34_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_34_1' id='label_11_34_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_34_2'> <input class='gfield-choice-input' name='input_34' type='radio' value='Not Sure' id='choice_11_34_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_34_2' id='label_11_34_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_166" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_166'><span class='gform-field-label__text'>Please list the medications that you are allergic to:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_11_166' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_11_164" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>What happened?</span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_164'> <div class='gchoice gchoice_11_164_0'> <input class='gfield-choice-input' name='input_164' type='radio' value='Rash' id='choice_11_164_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_164_0' id='label_11_164_0' class='gform-field-label gform-field-label--type-inline'>Rash</label> </div> <div class='gchoice gchoice_11_164_1'> <input class='gfield-choice-input' name='input_164' type='radio' value='Breathing problems/Wheezing' id='choice_11_164_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_164_1' id='label_11_164_1' class='gform-field-label gform-field-label--type-inline'>Breathing problems/Wheezing</label> </div> <div class='gchoice gchoice_11_164_2'> <input class='gfield-choice-input' name='input_164' type='radio' value='Swelling' id='choice_11_164_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_164_2' id='label_11_164_2' class='gform-field-label gform-field-label--type-inline'>Swelling</label> </div> <div class='gchoice gchoice_11_164_3'> <input class='gfield-choice-input' name='input_164' type='radio' value='Other' id='choice_11_164_3' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_164_3' id='label_11_164_3' class='gform-field-label gform-field-label--type-inline'>Other</label> </div></div></div></fieldset><div id="field_11_165" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_165'><span class='gform-field-label__text'>Untitled</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_11_165' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_11_135" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>7. Do you take any medications for Osteoporosis? ( examples Risedronate, Prolia, etc.)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_135'> <div class='gchoice gchoice_11_135_0'> <input class='gfield-choice-input' name='input_135' type='radio' value='Yes' id='choice_11_135_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_135_0' id='label_11_135_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_135_1'> <input class='gfield-choice-input' name='input_135' type='radio' value='No' id='choice_11_135_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_135_1' id='label_11_135_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_135_2'> <input class='gfield-choice-input' name='input_135' type='radio' value='Not Sure' id='choice_11_135_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_135_2' id='label_11_135_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_154" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_154'><span class='gform-field-label__text'>If Prolia, date of last injection:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_11_154' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_154' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_11_154' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_11_154' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_154' aria-label='If Prolia, date of last injection:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_11_153" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>8. Do you take 81 mg ASA, daily?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_153'> <div class='gchoice gchoice_11_153_0'> <input class='gfield-choice-input' name='input_153' type='radio' value='Yes' id='choice_11_153_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_153_0' id='label_11_153_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_153_1'> <input class='gfield-choice-input' name='input_153' type='radio' value='No' id='choice_11_153_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_153_1' id='label_11_153_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_153_2'> <input class='gfield-choice-input' name='input_153' type='radio' value='Not Sure' id='choice_11_153_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_153_2' id='label_11_153_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_174" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><span style="font-size:20px;font-weight:700">DO NOT STOP YOUR DAILY ASA</span></div><fieldset id="field_11_43" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>9. Do you have or have you ever had asthma?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_43'> <div class='gchoice gchoice_11_43_0'> <input class='gfield-choice-input' name='input_43' type='radio' value='Yes' id='choice_11_43_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_43_0' id='label_11_43_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_43_1'> <input class='gfield-choice-input' name='input_43' type='radio' value='No' id='choice_11_43_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_43_1' id='label_11_43_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_43_2'> <input class='gfield-choice-input' name='input_43' type='radio' value='Not Sure' id='choice_11_43_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_43_2' id='label_11_43_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_44" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>10. Do you have or have you ever had any heart or blood pressure problems?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_44'> <div class='gchoice gchoice_11_44_0'> <input class='gfield-choice-input' name='input_44' type='radio' value='Yes' id='choice_11_44_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_44_0' id='label_11_44_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_44_1'> <input class='gfield-choice-input' name='input_44' type='radio' value='No' id='choice_11_44_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_44_1' id='label_11_44_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_44_2'> <input class='gfield-choice-input' name='input_44' type='radio' value='Not Sure' id='choice_11_44_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_44_2' id='label_11_44_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_45" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>11. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_45'> <div class='gchoice gchoice_11_45_0'> <input class='gfield-choice-input' name='input_45' type='radio' value='Yes' id='choice_11_45_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_45_0' id='label_11_45_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_45_1'> <input class='gfield-choice-input' name='input_45' type='radio' value='No' id='choice_11_45_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_45_1' id='label_11_45_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_45_2'> <input class='gfield-choice-input' name='input_45' type='radio' value='Not Sure' id='choice_11_45_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_45_2' id='label_11_45_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_46" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>12. Do you have a prosthetic or artificial joint?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_46'> <div class='gchoice gchoice_11_46_0'> <input class='gfield-choice-input' name='input_46' type='radio' value='Yes' id='choice_11_46_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_46_0' id='label_11_46_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_46_1'> <input class='gfield-choice-input' name='input_46' type='radio' value='No' id='choice_11_46_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_46_1' id='label_11_46_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_11_47" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>13. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_47'> <div class='gchoice gchoice_11_47_0'> <input class='gfield-choice-input' name='input_47' type='radio' value='Yes' id='choice_11_47_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_47_0' id='label_11_47_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_47_1'> <input class='gfield-choice-input' name='input_47' type='radio' value='No' id='choice_11_47_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_47_1' id='label_11_47_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_47_2'> <input class='gfield-choice-input' name='input_47' type='radio' value='Not Sure' id='choice_11_47_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_47_2' id='label_11_47_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_48" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>14. Have you ever had hepatitis, jaundice or liver disease?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_48'> <div class='gchoice gchoice_11_48_0'> <input class='gfield-choice-input' name='input_48' type='radio' value='Yes' id='choice_11_48_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_48_0' id='label_11_48_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_48_1'> <input class='gfield-choice-input' name='input_48' type='radio' value='No' id='choice_11_48_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_48_1' id='label_11_48_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_48_2'> <input class='gfield-choice-input' name='input_48' type='radio' value='Not Sure' id='choice_11_48_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_48_2' id='label_11_48_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_49" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>15. Do you have a bleeding problem or bleeding disorder?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_49'> <div class='gchoice gchoice_11_49_0'> <input class='gfield-choice-input' name='input_49' type='radio' value='Yes' id='choice_11_49_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_49_0' id='label_11_49_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_49_1'> <input class='gfield-choice-input' name='input_49' type='radio' value='No' id='choice_11_49_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_49_1' id='label_11_49_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_49_2'> <input class='gfield-choice-input' name='input_49' type='radio' value='Not Sure' id='choice_11_49_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_49_2' id='label_11_49_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_50" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>16. Have you ever been hospitalized for any illnesses or operations?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_50'> <div class='gchoice gchoice_11_50_0'> <input class='gfield-choice-input' name='input_50' type='radio' value='Yes' id='choice_11_50_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_50_0' id='label_11_50_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_50_1'> <input class='gfield-choice-input' name='input_50' type='radio' value='No' id='choice_11_50_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_50_1' id='label_11_50_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_11_51" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_51'><span class='gform-field-label__text'>Explain:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_11_51' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_11_85" class="gfield gfield--type-html gfield--input-type-html gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>17. Do you have or have you ever had any of the following? </p></div><fieldset id="field_11_52" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart murmur:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_52'> <div class='gchoice gchoice_11_52_0'> <input class='gfield-choice-input' name='input_52' type='radio' value='Yes' id='choice_11_52_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_52_0' id='label_11_52_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_52_1'> <input class='gfield-choice-input' name='input_52' type='radio' value='No' id='choice_11_52_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_52_1' id='label_11_52_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_52_2'> <input class='gfield-choice-input' name='input_52' type='radio' value='Not Sure' id='choice_11_52_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_52_2' id='label_11_52_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_86" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart attack:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_86'> <div class='gchoice gchoice_11_86_0'> <input class='gfield-choice-input' name='input_86' type='radio' value='Yes' id='choice_11_86_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_86_0' id='label_11_86_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_86_1'> <input class='gfield-choice-input' name='input_86' type='radio' value='No' id='choice_11_86_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_86_1' id='label_11_86_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_86_2'> <input class='gfield-choice-input' name='input_86' type='radio' value='Not Sure' id='choice_11_86_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_86_2' id='label_11_86_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_87" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Chest pain or angina:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_87'> <div class='gchoice gchoice_11_87_0'> <input class='gfield-choice-input' name='input_87' type='radio' value='Yes' id='choice_11_87_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_87_0' id='label_11_87_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_87_1'> <input class='gfield-choice-input' name='input_87' type='radio' value='No' id='choice_11_87_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_87_1' id='label_11_87_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_87_2'> <input class='gfield-choice-input' name='input_87' type='radio' value='Not Sure' id='choice_11_87_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_87_2' id='label_11_87_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_88" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shortness of breath lying down:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_88'> <div class='gchoice gchoice_11_88_0'> <input class='gfield-choice-input' name='input_88' type='radio' value='Yes' id='choice_11_88_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_88_0' id='label_11_88_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_88_1'> <input class='gfield-choice-input' name='input_88' type='radio' value='No' id='choice_11_88_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_88_1' id='label_11_88_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_88_2'> <input class='gfield-choice-input' name='input_88' type='radio' value='Not Sure' id='choice_11_88_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_88_2' id='label_11_88_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_89" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Swollen ankles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_89'> <div class='gchoice gchoice_11_89_0'> <input class='gfield-choice-input' name='input_89' type='radio' value='Yes' id='choice_11_89_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_89_0' id='label_11_89_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_89_1'> <input class='gfield-choice-input' name='input_89' type='radio' value='No' id='choice_11_89_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_89_1' id='label_11_89_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_89_2'> <input class='gfield-choice-input' name='input_89' type='radio' value='Not Sure' id='choice_11_89_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_89_2' id='label_11_89_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_90" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart pacemaker/defibrillator:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_90'> <div class='gchoice gchoice_11_90_0'> <input class='gfield-choice-input' name='input_90' type='radio' value='Yes' id='choice_11_90_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_90_0' id='label_11_90_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_90_1'> <input class='gfield-choice-input' name='input_90' type='radio' value='No' id='choice_11_90_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_90_1' id='label_11_90_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_90_2'> <input class='gfield-choice-input' name='input_90' type='radio' value='Not Sure' id='choice_11_90_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_90_2' id='label_11_90_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_91" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Irregular heart beat/arrhythmia:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_91'> <div class='gchoice gchoice_11_91_0'> <input class='gfield-choice-input' name='input_91' type='radio' value='Yes' id='choice_11_91_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_91_0' id='label_11_91_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_91_1'> <input class='gfield-choice-input' name='input_91' type='radio' value='No' id='choice_11_91_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_91_1' id='label_11_91_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_91_2'> <input class='gfield-choice-input' name='input_91' type='radio' value='Not Sure' id='choice_11_91_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_91_2' id='label_11_91_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_92" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>High blood pressure:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_92'> <div class='gchoice gchoice_11_92_0'> <input class='gfield-choice-input' name='input_92' type='radio' value='Yes' id='choice_11_92_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_92_0' id='label_11_92_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_92_1'> <input class='gfield-choice-input' name='input_92' type='radio' value='No' id='choice_11_92_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_92_1' id='label_11_92_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_92_2'> <input class='gfield-choice-input' name='input_92' type='radio' value='Not Sure' id='choice_11_92_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_92_2' id='label_11_92_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_140" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shingles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_140'> <div class='gchoice gchoice_11_140_0'> <input class='gfield-choice-input' name='input_140' type='radio' value='Yes' id='choice_11_140_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_140_0' id='label_11_140_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_140_1'> <input class='gfield-choice-input' name='input_140' type='radio' value='No' id='choice_11_140_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_140_1' id='label_11_140_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_140_2'> <input class='gfield-choice-input' name='input_140' type='radio' value='Not Sure' id='choice_11_140_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_140_2' id='label_11_140_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_93" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Congenital heart disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_93'> <div class='gchoice gchoice_11_93_0'> <input class='gfield-choice-input' name='input_93' type='radio' value='Yes' id='choice_11_93_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_93_0' id='label_11_93_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_93_1'> <input class='gfield-choice-input' name='input_93' type='radio' value='No' id='choice_11_93_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_93_1' id='label_11_93_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_93_2'> <input class='gfield-choice-input' name='input_93' type='radio' value='Not Sure' id='choice_11_93_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_93_2' id='label_11_93_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_94" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Damaged/abnormal heart valves:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_94'> <div class='gchoice gchoice_11_94_0'> <input class='gfield-choice-input' name='input_94' type='radio' value='Yes' id='choice_11_94_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_94_0' id='label_11_94_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_94_1'> <input class='gfield-choice-input' name='input_94' type='radio' value='No' id='choice_11_94_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_94_1' id='label_11_94_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_94_2'> <input class='gfield-choice-input' name='input_94' type='radio' value='Not Sure' id='choice_11_94_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_94_2' id='label_11_94_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_95" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Rheumatic fever:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_95'> <div class='gchoice gchoice_11_95_0'> <input class='gfield-choice-input' name='input_95' type='radio' value='Yes' id='choice_11_95_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_95_0' id='label_11_95_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_95_1'> <input class='gfield-choice-input' name='input_95' type='radio' value='No' id='choice_11_95_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_95_1' id='label_11_95_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_95_2'> <input class='gfield-choice-input' name='input_95' type='radio' value='Not Sure' id='choice_11_95_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_95_2' id='label_11_95_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_96" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Kidney disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_96'> <div class='gchoice gchoice_11_96_0'> <input class='gfield-choice-input' name='input_96' type='radio' value='Yes' id='choice_11_96_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_96_0' id='label_11_96_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_96_1'> <input class='gfield-choice-input' name='input_96' type='radio' value='No' id='choice_11_96_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_96_1' id='label_11_96_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_96_2'> <input class='gfield-choice-input' name='input_96' type='radio' value='Not Sure' id='choice_11_96_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_96_2' id='label_11_96_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_97" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>HIV, AIDS or STD:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_97'> <div class='gchoice gchoice_11_97_0'> <input class='gfield-choice-input' name='input_97' type='radio' value='Yes' id='choice_11_97_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_97_0' id='label_11_97_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_97_1'> <input class='gfield-choice-input' name='input_97' type='radio' value='No' id='choice_11_97_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_97_1' id='label_11_97_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_97_2'> <input class='gfield-choice-input' name='input_97' type='radio' value='Not Sure' id='choice_11_97_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_97_2' id='label_11_97_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_100" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cancer / Chemotherapy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_100'> <div class='gchoice gchoice_11_100_0'> <input class='gfield-choice-input' name='input_100' type='radio' value='Yes' id='choice_11_100_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_100_0' id='label_11_100_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_100_1'> <input class='gfield-choice-input' name='input_100' type='radio' value='No' id='choice_11_100_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_100_1' id='label_11_100_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_100_2'> <input class='gfield-choice-input' name='input_100' type='radio' value='Not Sure' id='choice_11_100_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_100_2' id='label_11_100_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_101" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been screened for Sleep Apnea?:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_101'> <div class='gchoice gchoice_11_101_0'> <input class='gfield-choice-input' name='input_101' type='radio' value='Yes' id='choice_11_101_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_101_0' id='label_11_101_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_101_1'> <input class='gfield-choice-input' name='input_101' type='radio' value='No' id='choice_11_101_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_101_1' id='label_11_101_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_101_2'> <input class='gfield-choice-input' name='input_101' type='radio' value='Not Sure' id='choice_11_101_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_101_2' id='label_11_101_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_167" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been diagnosed with Sleep Apnea?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_167'> <div class='gchoice gchoice_11_167_0'> <input class='gfield-choice-input' name='input_167' type='radio' value='Yes' id='choice_11_167_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_167_0' id='label_11_167_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_167_1'> <input class='gfield-choice-input' name='input_167' type='radio' value='No' id='choice_11_167_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_167_1' id='label_11_167_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_167_2'> <input class='gfield-choice-input' name='input_167' type='radio' value='Not Sure' id='choice_11_167_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_167_2' id='label_11_167_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_102" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Asthma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_102'> <div class='gchoice gchoice_11_102_0'> <input class='gfield-choice-input' name='input_102' type='radio' value='Yes' id='choice_11_102_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_102_0' id='label_11_102_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_102_1'> <input class='gfield-choice-input' name='input_102' type='radio' value='No' id='choice_11_102_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_102_1' id='label_11_102_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_102_2'> <input class='gfield-choice-input' name='input_102' type='radio' value='Not Sure' id='choice_11_102_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_102_2' id='label_11_102_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_103" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Emphysema / Bronchitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_103'> <div class='gchoice gchoice_11_103_0'> <input class='gfield-choice-input' name='input_103' type='radio' value='Yes' id='choice_11_103_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_103_0' id='label_11_103_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_103_1'> <input class='gfield-choice-input' name='input_103' type='radio' value='No' id='choice_11_103_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_103_1' id='label_11_103_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_103_2'> <input class='gfield-choice-input' name='input_103' type='radio' value='Not Sure' id='choice_11_103_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_103_2' id='label_11_103_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_104" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cystic fibrosis / Tuberculosis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_104'> <div class='gchoice gchoice_11_104_0'> <input class='gfield-choice-input' name='input_104' type='radio' value='Yes' id='choice_11_104_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_104_0' id='label_11_104_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_104_1'> <input class='gfield-choice-input' name='input_104' type='radio' value='No' id='choice_11_104_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_104_1' id='label_11_104_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_104_2'> <input class='gfield-choice-input' name='input_104' type='radio' value='Not Sure' id='choice_11_104_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_104_2' id='label_11_104_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_105" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Epilepsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_105'> <div class='gchoice gchoice_11_105_0'> <input class='gfield-choice-input' name='input_105' type='radio' value='Yes' id='choice_11_105_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_105_0' id='label_11_105_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_105_1'> <input class='gfield-choice-input' name='input_105' type='radio' value='No' id='choice_11_105_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_105_1' id='label_11_105_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_105_2'> <input class='gfield-choice-input' name='input_105' type='radio' value='Not Sure' id='choice_11_105_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_105_2' id='label_11_105_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_106" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stroke:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_106'> <div class='gchoice gchoice_11_106_0'> <input class='gfield-choice-input' name='input_106' type='radio' value='Yes' id='choice_11_106_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_106_0' id='label_11_106_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_106_1'> <input class='gfield-choice-input' name='input_106' type='radio' value='No' id='choice_11_106_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_106_1' id='label_11_106_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_106_2'> <input class='gfield-choice-input' name='input_106' type='radio' value='Not Sure' id='choice_11_106_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_106_2' id='label_11_106_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_107" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Fainting spells, dizziness:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_107'> <div class='gchoice gchoice_11_107_0'> <input class='gfield-choice-input' name='input_107' type='radio' value='Yes' id='choice_11_107_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_107_0' id='label_11_107_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_107_1'> <input class='gfield-choice-input' name='input_107' type='radio' value='No' id='choice_11_107_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_107_1' id='label_11_107_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_107_2'> <input class='gfield-choice-input' name='input_107' type='radio' value='Not Sure' id='choice_11_107_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_107_2' id='label_11_107_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_108" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Diabetes:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_108'> <div class='gchoice gchoice_11_108_0'> <input class='gfield-choice-input' name='input_108' type='radio' value='Yes' id='choice_11_108_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_108_0' id='label_11_108_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_108_1'> <input class='gfield-choice-input' name='input_108' type='radio' value='No' id='choice_11_108_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_108_1' id='label_11_108_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_108_2'> <input class='gfield-choice-input' name='input_108' type='radio' value='Not Sure' id='choice_11_108_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_108_2' id='label_11_108_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_109" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Thyroid Disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_109'> <div class='gchoice gchoice_11_109_0'> <input class='gfield-choice-input' name='input_109' type='radio' value='Yes' id='choice_11_109_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_109_0' id='label_11_109_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_109_1'> <input class='gfield-choice-input' name='input_109' type='radio' value='No' id='choice_11_109_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_109_1' id='label_11_109_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_109_2'> <input class='gfield-choice-input' name='input_109' type='radio' value='Not Sure' id='choice_11_109_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_109_2' id='label_11_109_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_110" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Adrenal gland disorder:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_110'> <div class='gchoice gchoice_11_110_0'> <input class='gfield-choice-input' name='input_110' type='radio' value='Yes' id='choice_11_110_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_110_0' id='label_11_110_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_110_1'> <input class='gfield-choice-input' name='input_110' type='radio' value='No' id='choice_11_110_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_110_1' id='label_11_110_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_110_2'> <input class='gfield-choice-input' name='input_110' type='radio' value='Not Sure' id='choice_11_110_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_110_2' id='label_11_110_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_111" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Hepatitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_111'> <div class='gchoice gchoice_11_111_0'> <input class='gfield-choice-input' name='input_111' type='radio' value='Yes' id='choice_11_111_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_111_0' id='label_11_111_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_111_1'> <input class='gfield-choice-input' name='input_111' type='radio' value='No' id='choice_11_111_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_111_1' id='label_11_111_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_111_2'> <input class='gfield-choice-input' name='input_111' type='radio' value='Not Sure' id='choice_11_111_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_111_2' id='label_11_111_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_112" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Liver disease / Jaundice:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_112'> <div class='gchoice gchoice_11_112_0'> <input class='gfield-choice-input' name='input_112' type='radio' value='Yes' id='choice_11_112_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_112_0' id='label_11_112_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_112_1'> <input class='gfield-choice-input' name='input_112' type='radio' value='No' id='choice_11_112_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_112_1' id='label_11_112_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_112_2'> <input class='gfield-choice-input' name='input_112' type='radio' value='Not Sure' id='choice_11_112_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_112_2' id='label_11_112_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_113" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Anemia (including sickle cell):</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_113'> <div class='gchoice gchoice_11_113_0'> <input class='gfield-choice-input' name='input_113' type='radio' value='Yes' id='choice_11_113_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_113_0' id='label_11_113_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_113_1'> <input class='gfield-choice-input' name='input_113' type='radio' value='No' id='choice_11_113_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_113_1' id='label_11_113_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_113_2'> <input class='gfield-choice-input' name='input_113' type='radio' value='Not Sure' id='choice_11_113_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_113_2' id='label_11_113_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_114" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Blood disorders/transfusions:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_114'> <div class='gchoice gchoice_11_114_0'> <input class='gfield-choice-input' name='input_114' type='radio' value='Yes' id='choice_11_114_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_114_0' id='label_11_114_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_114_1'> <input class='gfield-choice-input' name='input_114' type='radio' value='No' id='choice_11_114_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_114_1' id='label_11_114_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_114_2'> <input class='gfield-choice-input' name='input_114' type='radio' value='Not Sure' id='choice_11_114_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_114_2' id='label_11_114_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_115" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bleeding (Coagulation) disorders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_115'> <div class='gchoice gchoice_11_115_0'> <input class='gfield-choice-input' name='input_115' type='radio' value='Yes' id='choice_11_115_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_115_0' id='label_11_115_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_115_1'> <input class='gfield-choice-input' name='input_115' type='radio' value='No' id='choice_11_115_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_115_1' id='label_11_115_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_115_2'> <input class='gfield-choice-input' name='input_115' type='radio' value='Not Sure' id='choice_11_115_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_115_2' id='label_11_115_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_116" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stomach ulcers/ Acid Reflux:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_116'> <div class='gchoice gchoice_11_116_0'> <input class='gfield-choice-input' name='input_116' type='radio' value='Yes' id='choice_11_116_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_116_0' id='label_11_116_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_116_1'> <input class='gfield-choice-input' name='input_116' type='radio' value='No' id='choice_11_116_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_116_1' id='label_11_116_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_116_2'> <input class='gfield-choice-input' name='input_116' type='radio' value='Not Sure' id='choice_11_116_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_116_2' id='label_11_116_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_117" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bone, joint, or muscle problems:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_117'> <div class='gchoice gchoice_11_117_0'> <input class='gfield-choice-input' name='input_117' type='radio' value='Yes' id='choice_11_117_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_117_0' id='label_11_117_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_117_1'> <input class='gfield-choice-input' name='input_117' type='radio' value='No' id='choice_11_117_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_117_1' id='label_11_117_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_117_2'> <input class='gfield-choice-input' name='input_117' type='radio' value='Not Sure' id='choice_11_117_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_117_2' id='label_11_117_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_118" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Artificial joints - hips, knees, shoulders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_118'> <div class='gchoice gchoice_11_118_0'> <input class='gfield-choice-input' name='input_118' type='radio' value='Yes' id='choice_11_118_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_118_0' id='label_11_118_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_118_1'> <input class='gfield-choice-input' name='input_118' type='radio' value='No' id='choice_11_118_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_118_1' id='label_11_118_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_118_2'> <input class='gfield-choice-input' name='input_118' type='radio' value='Not Sure' id='choice_11_118_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_118_2' id='label_11_118_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_155" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_155'><span class='gform-field-label__text'>Date of replacement:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_11_155' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_155' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_11_155' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_11_155' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_155' aria-label='Date of replacement:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_11_119" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Arthritis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_119'> <div class='gchoice gchoice_11_119_0'> <input class='gfield-choice-input' name='input_119' type='radio' value='Yes' id='choice_11_119_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_119_0' id='label_11_119_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_119_1'> <input class='gfield-choice-input' name='input_119' type='radio' value='No' id='choice_11_119_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_119_1' id='label_11_119_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_119_2'> <input class='gfield-choice-input' name='input_119' type='radio' value='Not Sure' id='choice_11_119_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_119_2' id='label_11_119_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_120" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Depression / anxiety:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_120'> <div class='gchoice gchoice_11_120_0'> <input class='gfield-choice-input' name='input_120' type='radio' value='Yes' id='choice_11_120_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_120_0' id='label_11_120_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_120_1'> <input class='gfield-choice-input' name='input_120' type='radio' value='No' id='choice_11_120_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_120_1' id='label_11_120_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_120_2'> <input class='gfield-choice-input' name='input_120' type='radio' value='Not Sure' id='choice_11_120_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_120_2' id='label_11_120_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_121" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Vision problems / glaucoma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_121'> <div class='gchoice gchoice_11_121_0'> <input class='gfield-choice-input' name='input_121' type='radio' value='Yes' id='choice_11_121_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_121_0' id='label_11_121_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_121_1'> <input class='gfield-choice-input' name='input_121' type='radio' value='No' id='choice_11_121_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_121_1' id='label_11_121_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_121_2'> <input class='gfield-choice-input' name='input_121' type='radio' value='Not Sure' id='choice_11_121_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_121_2' id='label_11_121_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_122" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>People with intellectual/cognitive disabilities:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_122'> <div class='gchoice gchoice_11_122_0'> <input class='gfield-choice-input' name='input_122' type='radio' value='Yes' id='choice_11_122_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_122_0' id='label_11_122_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_122_1'> <input class='gfield-choice-input' name='input_122' type='radio' value='No' id='choice_11_122_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_122_1' id='label_11_122_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_122_2'> <input class='gfield-choice-input' name='input_122' type='radio' value='Not Sure' id='choice_11_122_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_122_2' id='label_11_122_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_123" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cerebral palsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_123'> <div class='gchoice gchoice_11_123_0'> <input class='gfield-choice-input' name='input_123' type='radio' value='Yes' id='choice_11_123_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_123_0' id='label_11_123_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_123_1'> <input class='gfield-choice-input' name='input_123' type='radio' value='No' id='choice_11_123_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_123_1' id='label_11_123_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_123_2'> <input class='gfield-choice-input' name='input_123' type='radio' value='Not Sure' id='choice_11_123_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_123_2' id='label_11_123_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_124" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Autism or Down&#039;s syndrome:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_124'> <div class='gchoice gchoice_11_124_0'> <input class='gfield-choice-input' name='input_124' type='radio' value='Yes' id='choice_11_124_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_124_0' id='label_11_124_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_124_1'> <input class='gfield-choice-input' name='input_124' type='radio' value='No' id='choice_11_124_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_124_1' id='label_11_124_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_124_2'> <input class='gfield-choice-input' name='input_124' type='radio' value='Not Sure' id='choice_11_124_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_124_2' id='label_11_124_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_125" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_125'> <div class='gchoice gchoice_11_125_0'> <input class='gfield-choice-input' name='input_125' type='radio' value='Yes' id='choice_11_125_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_125_0' id='label_11_125_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_125_1'> <input class='gfield-choice-input' name='input_125' type='radio' value='No' id='choice_11_125_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_125_1' id='label_11_125_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_125_2'> <input class='gfield-choice-input' name='input_125' type='radio' value='Not Sure' id='choice_11_125_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_125_2' id='label_11_125_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_126" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you a nursing mother?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_126'> <div class='gchoice gchoice_11_126_0'> <input class='gfield-choice-input' name='input_126' type='radio' value='Yes' id='choice_11_126_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_126_0' id='label_11_126_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_126_1'> <input class='gfield-choice-input' name='input_126' type='radio' value='No' id='choice_11_126_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_126_1' id='label_11_126_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_126_2'> <input class='gfield-choice-input' name='input_126' type='radio' value='Not Sure' id='choice_11_126_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_126_2' id='label_11_126_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_127" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Any problems with menstruation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_127'> <div class='gchoice gchoice_11_127_0'> <input class='gfield-choice-input' name='input_127' type='radio' value='Yes' id='choice_11_127_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_127_0' id='label_11_127_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_127_1'> <input class='gfield-choice-input' name='input_127' type='radio' value='No' id='choice_11_127_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_127_1' id='label_11_127_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_127_2'> <input class='gfield-choice-input' name='input_127' type='radio' value='Not Sure' id='choice_11_127_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_127_2' id='label_11_127_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_54" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>18. Are there any conditions or diseases not listed above that you have or have had?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_54'> <div class='gchoice gchoice_11_54_0'> <input class='gfield-choice-input' name='input_54' type='radio' value='Yes' id='choice_11_54_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_54_0' id='label_11_54_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_54_1'> <input class='gfield-choice-input' name='input_54' type='radio' value='No' id='choice_11_54_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_54_1' id='label_11_54_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_54_2'> <input class='gfield-choice-input' name='input_54' type='radio' value='Not Sure' id='choice_11_54_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_54_2' id='label_11_54_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_138" class="gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_138'><span class='gform-field-label__text'>Explain :</span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_138' id='input_11_138' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_11_57" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>19. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_57'> <div class='gchoice gchoice_11_57_0'> <input class='gfield-choice-input' name='input_57' type='radio' value='Yes' id='choice_11_57_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_57_0' id='label_11_57_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_57_1'> <input class='gfield-choice-input' name='input_57' type='radio' value='No' id='choice_11_57_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_57_1' id='label_11_57_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_57_2'> <input class='gfield-choice-input' name='input_57' type='radio' value='Not Sure' id='choice_11_57_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_57_2' id='label_11_57_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_139" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_139'><span class='gform-field-label__text'>Explain:</span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_139' id='input_11_139' class='textarea small' aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_11_59" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>20. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_59'> <div class='gchoice gchoice_11_59_0'> <input class='gfield-choice-input' name='input_59' type='radio' value='Yes' id='choice_11_59_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_59_0' id='label_11_59_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_59_1'> <input class='gfield-choice-input' name='input_59' type='radio' value='No' id='choice_11_59_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_59_1' id='label_11_59_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_59_2'> <input class='gfield-choice-input' name='input_59' type='radio' value='Not Sure' id='choice_11_59_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_59_2' id='label_11_59_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_157" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_157'><span class='gform-field-label__text'>When?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_11_157' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_157' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_11_157' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_11_157' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_157' aria-label='When?: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><div id="field_11_158" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_158'><span class='gform-field-label__text'>Where?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_11_158' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_11_159" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_159'><span class='gform-field-label__text'>Name of oncologist:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_159' id='input_11_159' class='textarea small' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_11_156" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>20. Do you smoke or chew tobacco products?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_156'> <div class='gchoice gchoice_11_156_0'> <input class='gfield-choice-input' name='input_156' type='radio' value='Yes' id='choice_11_156_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_156_0' id='label_11_156_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_156_1'> <input class='gfield-choice-input' name='input_156' type='radio' value='No' id='choice_11_156_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_156_1' id='label_11_156_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_156_2'> <input class='gfield-choice-input' name='input_156' type='radio' value='Not Sure' id='choice_11_156_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_156_2' id='label_11_156_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_11_60" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>21. For women only: Are you breastfeeding or pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_11_60'> <div class='gchoice gchoice_11_60_0'> <input class='gfield-choice-input' name='input_60' type='radio' value='Yes' id='choice_11_60_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_60_0' id='label_11_60_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_11_60_1'> <input class='gfield-choice-input' name='input_60' type='radio' value='No' id='choice_11_60_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_60_1' id='label_11_60_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_11_60_2'> <input class='gfield-choice-input' name='input_60' type='radio' value='Not Sure' id='choice_11_60_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_11_60_2' id='label_11_60_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_11_61" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_11_61'><span class='gform-field-label__text'>If pregnant, what is the expected delivery date?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_11_61' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_61' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_11_61' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_11_61' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_11_61' aria-label='If pregnant, what is the expected delivery date?: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_11_150" class="gfield gfield--type-signature gfield--in
226put-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Signature</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_container ginput_container_signature"><input type='hidden' value='' name='input_150' id='input_11_150_signature_filename' class='gfield_signature_filename' /><div class='gfield_signature_ui_container gform-theme__no-reset--children'><div id='input_11_150_Container' class='gfield_signature_container' style='height:90px;width:300px'><input type='hidden' id='input_11_150_data' name='input_11_150_data' class='gfield_signature_data' /><canvas id="input_11_150" width="300" height="90" style="border-style:Dashed;border-width:2px;border-color:#757575;background-color:#fff;cursor:url(&quot;https://summitheightsdental.com/nitropack_static/FvibRvOpvKUPQoFPcmVkuTtolIergKoe/assets/desktop/source/rev-c5c7266/summitheightsdental.com/wp-content/plugins/gravityformssignature/assets/img/pen.cur&quot;),pointer" tabindex="0" aria-label="Signature pad"></canvas><input type='text' id='input_11_150_textinput' name='input_11_150_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:300px;height:90px;border-style:Dashed;border-width:2px;border-color:#757575;background-color:#fff;font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#000' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' /></div><div id='input_11_150_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:300px;max-width:100%;display:flex;align-items:center'><div id='input_11_150_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0'></div><input type='hidden' id='input_11_150_font_select' class='gfield_signature_font_select' value='script' /><div id='input_11_150_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'></span><button type='button' id='input_11_150_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;color:#000'>Your Name</button><ul id='input_11_150_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;,&quot;Segoe Script&quot;,cursive;color:#000' aria-label='Your Name, Script style'>Your Name</li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;,&quot;Comic Sans MS&quot;,cursive;color:#000' aria-label='Your Name, Handwritten style'>Your Name</li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;,&quot;Segoe Print&quot;,cursive;color:#000' aria-label='Your Name, Print style'>Your Name</li></ul></div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center'><button type='button' id='input_11_150_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Text Signature' aria-label='Text Signature'></button><button type='button' id='input_11_150_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Draw Signature' aria-label='Draw Signature'></button><button type='button' id='input_11_150_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer' alt='Clear Signature' aria-label='Clear Signature'></button></div></div></div></div></fieldset><fieldset id="field_11_151" class="gfield gfield--type-consent gfield--type-choice gfield--in
226put-type-consent gfield--width-full pri-check gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Consent</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_consent'><input name='input_151.1' id='input_11_151_1' type='checkbox' value='1' aria-required="true" aria-invalid="false" /> <label class="gform-field-label gform-field-label--type-inline gfield_consent_label" for='input_11_151_1'><span class='gform-field-label__text'>By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our <a href="/privacy-policy/">Privacy Policy</a>.</span><span class="gfield_required gfield_required_asterisk">*</span></label><input type='hidden' name='input_151.2' value='By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our &lt;a href=&quot;/privacy-policy/&quot;&gt;Privacy Policy&lt;/a&gt;.' class='gform_hidden' /><input type='hidden' name='input_151.3' value='5' class='gform_hidden' /></div></fieldset><fieldset id="field_11_169" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Untitled</span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_11_169'><div class='gchoice gchoice_11_169_1'> <input class='gfield-choice-input' name='input_169.1' type='checkbox' value='First Choice' id='choice_11_169_1' /> <label for='choice_11_169_1' id='label_11_169_1' class='gform-field-label gform-field-label--type-inline'>First Choice</label> </div><div class='gchoice gchoice_11_169_2'> <input class='gfield-choice-input' name='input_169.2' type='checkbox' value='Second Choice' id='choice_11_169_2' /> <label for='choice_11_169_2' id='label_11_169_2' class='gform-field-label gform-field-label--type-inline'>Second Choice</label> </div><div class='gchoice gchoice_11_169_3'> <input class='gfield-choice-input' name='input_169.3' type='checkbox' value='Third Choice' id='choice_11_169_3' /> <label for='choice_11_169_3' id='label_11_169_3' class='gform-field-label gform-field-label--type-inline'>Third Choice</label> </div></div></div></fieldset></div></div> <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_11' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='submit' id='gform_submit_button_11' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit'>Submit</button> <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_11' value='postback' /> <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_11' id='gform_theme_11' value='gravity-theme' /> <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_11' id='gform_style_settings_11' value='[]' /> <input type='hidden' class='gform_hidden' name='is_submit_11' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='11' /> <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='E1po/X/tr6ISd6NgHxCUZRIEOSnhD75Ph7WfNolzGUlnsARa7gs71/F4cpwEqlIF67xRxdGk/3VmwdGyA8/+MWkHwoQkl8/FOP++E2obQb6gwiM=' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_11' value='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226<div id="field_10_2" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH</h5> <h5>WHAT IS AN IMPACTED TOOTH?</h5> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <p>An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them.</p> <h5>WHAT HARM CAN IMPACTED TEETH DO?</h5> <p></p><ol><li>Impacted teeth may grow in any direction; however they often grow forward and push against the adjacent second molar. This can result in pain in the second molar and possibly damage to the roots or crown. The second molar may also be pushed out of position.</li> <li>All teeth develop in sacs deep in the bone. If the tooth erupts normally, the sac generally disappears. If the tooth is impacted, the sac can fill with fluid and enlarge to form a cyst. The cyst can cause destruction of surrounding bone and damage to other teeth in the area.</li> <li>Whenever saliva can reach the tooth, decay may occur, and since such cavities cannot be filled severe pain may result. This may be followed by the formation of an abscess.</li> <li>Bacteria in the saliva may cause an infection around the crown of the wisdom tooth and under the flap of gum tissue which may be covering part of the tooth. This infection may spread to the cheek, throat or neck and result in severe pain, stiffness of the jaws, fever, and severe generalized illness.</li> <li>Pressure from the wisdom teeth may cause crowding of the front teeth. This is why some orthodontists do not consider orthodontic treatment complete until impacted third molars have been removed.</li></ol><p></p> <h5>WHEN IS IT BEST TO HAVE WISDOM TEETH REMOVED?</h5> <p>The dentist can study x-rays of the teeth and jaws, and can frequently tell by the teen years if the wisdom teeth are going to be impacted. At this stage the roots are usually not fully formed in most people and the bone is less dense. Therefore, the wisdom teeth are less complicated to remove and the healing is generally faster.</p> <h5>WHAT IS IT LIKE TO HAVE AN IMPACTED TOOTH REMOVED?</h5> <p>Because the impacted tooth is usually completely beneath the surface of the gum and often encased in bone, we consider its removal an operation in every sense of the word. This is said not to frighten the prospective patient, but rather to give a better understanding about certain features regarding cost, careful preparations and the need for good aftercare. Either local and general anaesthesia or local and sedation may be used. The dentist chooses the method of treatment based on each individual situation. Having a comfortable patient helps to control bleeding, allows the dentist to work without haste and causes less physiological disturbance to the patient. The actual removal of the tooth is done in keeping with recognized surgical principles, with meticulously sterile instruments, good light, a dry operative field, gentle handling of the soft tissue and bone and the advantages of a well trained team. Depending on the degree of difficulty of the individual case, the procedure may last from fifteen to sixty minutes. If sedation or general anaesthesia is used there will be a recovery period from thirty to ninety minutes. The surgical wound may be sutured with a material of the dentist’s choice. Most often dissolving sutures are used.</p> <h5>WHAT SHOULD I EXPECT AFTER SURGERY?</h5> <p>After any surgical procedure a certain amount of discomfort is anticipated. For this reason you will be provided with pain relieving medication before you leave the office. You are to take your pain medication as directed by the dentist; instructions will be on the bottle. Your dentist will decide if antibiotic medication is necessary and if this medication has been prescribed then it should be taken until all tablets are gone. Swelling after surgery is normal. You should expect to be most swollen forty eight to seventy two hours after surgery. The swelling then begins to resolve. Certain individuals have bruising after wisdom teeth surgery. The bruising may extend into the neck and chest. This should not alarm you as in some individuals this is the normal sequence of events.</p> <p>Stiffness of the jaws is also normal after wisdom teeth surgery and is usually at its worst two or three days after surgery. One should start to exercise the jaws on the second or third post operative day to return the jaws to normal.</p> <p>Although it will probably be difficult to eat after surgery in the mouth one must remember that the body heals itself by drawing upon its reserves of protein, vitamins, minerals, calcium and iron. Failure to replenish the body’s supplies of the above mentioned nutrients can result in fatigue, infections and even delayed healing. For the first twenty-four hours following surgery your food and beverages should be warm or cold NOT HOT. Eggs, custards, yogurt, milkshakes, baby food, etc., are both nutritious and manageable. Fluid intake should be approximately two litres or eight juice glasses per day for the average adult.</p> <p>Detailed post operative instructions will be provided before you leave the office.</p> <h5>ARE THERE ANY COMPLICATIONS OR RISKS?</h5> <p>Any operation carries some degree of risk. This risk is minimized by careful preoperative assessment of your physical condition, by careful examination of all of the diagnostic materials, by careful preparation of instruments and all facilities, and by the skill of your dental team. The most commonly encountered complications will be discussed below.</p> <p>Post-operative bleeding is usually encountered when the patient has not placed the gauze pack DIRECTLY over the surgical site. Pressure over the site for forty-five to sixty minutes will control most post-operative bleeding. If you are still concerned call the office and the problem will be dealt with promptly.</p> <p>A condition known as dry socket occurs in approximately five percent of patients. It is more common in smokers and in female patients on the pill. It is manifest by a dull throbbing pain which starts five or seven days after the operation and is accompanied by a foul odour from the mouth. The treatment for this problem is simple and consists of two or three dressing changes. Healing is slightly slower than normal.</p> <p>The roots of lower impacted teeth very often rest on and around the main nerve of the lower jaw. Very rarely, in spite of all precautions, during the removal of lower third molars this nerve is bruised, slightly lacerated or even severed. The result will be numbness of the lower lip, chin, and all of the teeth on that side. This effect does not last longer than a few weeks in most cases. It improves as the nerve repairs itself and regenerates. Occasionally the numbness may last as long as two or five years and even more rarely it may be permanent .Also in the region of the lower third molar is the nerve which supplies sensation to the lateral part of the tongue. It may on occasion be stretched with a resultant numb tongue. This problem usually resolves within several weeks or months. Upper impacted third molars lie against the wall of the sinus. Great care is taken to insure that no injury occurs to this structure but occasionally the thin wall of bone cracks and blood seeps into the sinus. Occasionally there may be formed a communication between the sinus and the mouth. If your dentist suspects this to be the case you will be informed and additional medication will be prescribed. Infections after the removal of wisdom teeth are rare. Redness, increasing swelling after an initial decrease, foul tasting discharge into the mouth, fever and chills are all signs if infection. If these should appear call the office and you will be attended to promptly.</p> <p>Occasionally large fillings in the second molar teeth may be loosened or cracked during the removal of the wisdom teeth in spite of immaculate care and skill. If the possibility of this exists prior to surgery, you will be informed.</p> <p>Another very rare complication is a cracked or fractured lower jaw. This occurs when the wisdom tooth is very severely impacted. If your dentist is concerned about this possibility, you will be informed.</p> <p>Dr. Brian Kumer<br /><a href="tel:4166050008">(416) 605-0008 </a></p> </div><fieldset id="field_10_57" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_57'><div class='gchoice gchoice_10_57_1'> <input class='gfield-choice-input' name='input_57.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_10_57_1' /> <label for='choice_10_57_1' id='label_10_57_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_next_button_10_4' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-4' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_10_5" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ORAL SURGERY CONSENT FORM</h5> <h5>SWELLING, BRUISING AND PAIN</h5> <p>These can occur with any surgery and vary between patients and from one surgery to another. You may require several days at home for recovery. You may also have stretching of the corners of the mouth that may cause bruising and may heal slowly.</p></div><fieldset id="field_10_58" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SWELLING, BRUISING AND PAIN</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_58'><div class='gchoice gchoice_10_58_1'> <input class='gfield-choice-input' name='input_58.1' type='checkbox' value='I have read and understand this section.' id='choice_10_58_1' /> <label for='choice_10_58_1' id='label_10_58_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_55" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TRISMUS</h5> <p>This is the limited opening of the jaws due to inflammation in the muscles. This is more common with impacted tooth removal but is possible with almost any surgery. There is a higher likelihood if TMJ (see below) problem already exists.</p></div><fieldset id="field_10_172" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TRISMUS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
226<div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_172'><div class='gchoice gchoice_10_172_1'> <input class='gfield-choice-input' name='input_172.1' type='checkbox' value='I have read and understand this section.' id='choice_10_172_1' /> <label for='choice_10_172_1' id='label_10_172_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_168" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INFECTION</h5> <p>This is possible with any surgical procedure and may require further surgery and/or medications if it does occur.</p></div><fieldset id="field_10_173" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INFECTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_173'><div class='gchoice gchoice_10_173_1'> <input class='gfield-choice-input' name='input_173.1' type='checkbox' value='I have read and understand this section.' id='choice_10_173_1' /> <label for='choice_10_173_1' id='label_10_173_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_167" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>BLEEDING</h5> <p>Although significant bleeding can occur during or after surgery, it is not common. Some bleeding is, however, expected with most surgeries and is normally controlled by following the post-op instruction sheet. Prolonged or heavy bleeding may require additional treatment.</p></div><fieldset id="field_10_174" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>BLEEDING</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_174'><div class='gchoice gchoice_10_174_1'> <input class='gfield-choice-input' name='input_174.1' type='checkbox' value='I have read and understand this section.' id='choice_10_174_1' /> <label for='choice_10_174_1' id='label_10_174_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_169" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>TMJ DYSFUNCTION</h5> <p>This means the jaw joint (Tempromandibular Joint) may not function properly and, although rare, may require treatment ranging from use of hot/cold compress and rest to further surgery.</p></div><fieldset id="field_10_175" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>TMJ DYSFUNCTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_175'><div class='gchoice gchoice_10_175_1'> <input class='gfield-choice-input' name='input_175.1' type='checkbox' value='I have read and understand this section.' id='choice_10_175_1' /> <label for='choice_10_175_1' id='label_10_175_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_166" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>LOCAL ANAESTHESIA</h5> <p>Certain possible risks exist that, although uncommon or rare, could include pain, swelling, bruising, infection, nerve damage, idiosyncratic or allergic reactions.</p></div><fieldset id="field_10_176" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>LOCAL ANAESTHESIA</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_176'><div class='gchoice gchoice_10_176_1'> <input class='gfield-choice-input' name='input_176.1' type='checkbox' value='I have read and understand this section.' id='choice_10_176_1' /> <label for='choice_10_176_1' id='label_10_176_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_165" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>ALLERGIC REACTION</h5> <p>Allergic reaction, such as itching, rash, swelling, difficulty in breathing, is possible to any medication used it treatment.</p></div><fieldset id="field_10_177" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>ALLERGIC REACTION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_177'><div class='gchoice gchoice_10_177_1'> <input class='gfield-choice-input' name='input_177.1' type='checkbox' value='I have read and understand this section.' id='choice_10_177_1' /> <label for='choice_10_177_1' id='label_10_177_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_164" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DRY SOCKET</h5> <p>This is significant pain in the jaw and ear due to the loss of the blood clot and most commonly occurs after the removal of lower wisdom teeth, but it is possible with any extractions. Incidence increases with poor oral hygiene, smoking, birth control pill use. This may require additional office visits to treat.</p></div><fieldset id="field_10_178" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DRY SOCKET</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_178'><div class='gchoice gchoice_10_178_1'> <input class='gfield-choice-input' name='input_178.1' type='checkbox' value='I have read and understand this section.' id='choice_10_178_1' /> <label for='choice_10_178_1' id='label_10_178_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_163" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>DAMAGE TO OTHER TEETH AND FILLINGS</h5> <p>Due to the close proximity of teeth, it is possible to damage other teeth and/or fillings when a tooth is removed</p></div><fieldset id="field_10_179" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>DAMAGE TO OTHER TEETH AND FILLINGS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_179'><div class='gchoice gchoice_10_179_1'> <input class='gfield-choice-input' name='input_179.1' type='checkbox' value='I have read and understand this section.' id='choice_10_179_1' /> <label for='choice_10_179_1' id='label_10_179_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_162" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SHARP RIDGES AND BONE SPLINTERS</h5> <p>Occasionally, after an extraction, the edge of the socket will be sharp or a bone splinter will come out through the gum. This may require another surgery to smooth or remove the bone splinter.</p></div><fieldset id="field_10_180" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SHARP RIDGES AND BONE SPLINTERS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_180'><div class='gchoice gchoice_10_180_1'> <input class='gfield-choice-input' name='input_180.1' type='checkbox' value='I have read and understand this section.' id='choice_10_180_1' /> <label for='choice_10_180_1' id='label_10_180_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_161" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</h5> <p>There are times when the dentist may decide to leave in a fragment or root of a tooth in order to avoid doing damage to adjacent structures such as nerves, sinuses, etc. or if an extensive risk of other complications is present with its removal.</p></div><fieldset id="field_10_181" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>INCOMPLETE REMOVAL OF TOOTH FRAGMENTS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_181'><div class='gchoice gchoice_10_181_1'> <input class='gfield-choice-input' name='input_181.1' type='checkbox' value='I have read and understand this section.' id='choice_10_181_1' /> <label for='choice_10_181_1' id='label_10_181_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_160" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>NUMBNESS</h5> <p>Due to the proximity of roots to the nerve (especially wisdom teeth), it is possible to bruise or damage the nerve with removal of a tooth. This could remain for days, weeks, or very rarely, permanently. The lip, chin, cheek, gums and/or tongue could feel numb, tingling or have burning sensation.</p></div><fieldset id="field_10_182" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>NUMBNESS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_182'><div class='gchoice gchoice_10_182_1'> <input class='gfield-choice-input' name='input_182.1' type='checkbox' value='I have read and understand this section.' id='choice_10_182_1' /> <label for='choice_10_182_1' id='label_10_182_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_183" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>SINUS INVOLVEMENT</h5> <p>Due to the location of the roots (especially the upper back teeth) to the sinus, it is possible for an opening to develop from the sinus to the mouth. Or a tooth/fragment may be displaced into the sinus. A possible infection and/or permanent opening from the mouth into the sinus could develop and may require medication and/ or later surgery.</p></div><fieldset id="field_10_185" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>SINUS INVOLVEMENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_185'><div class='gchoice gchoice_10_185_1'> <input class='gfield-choice-input' name='input_185.1' type='checkbox' value='I have read and understand this section.' id='choice_10_185_1' /> <label for='choice_10_185_1' id='label_10_185_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_171" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>JAW FRACTURE</h5> <p>Fracture of the jaw, usually in more complicated extractions.</p></div><fieldset id="field_10_186" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>JAW FRACTURE</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_186'><div class='gchoice gchoice_10_186_1'> <input class='gfield-choice-input' name='input_186.1' type='checkbox' value='I have read and understand this section.' id='choice_10_186_1' /> <label for='choice_10_186_1' id='label_10_186_1' class='gform-field-label gform-field-label--type-inline'>I have read and understand this section.</label> </div></div></div></fieldset><div id="field_10_170" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>QUALIFICATION</h5> <p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions, including wisdom teeth and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p></div><fieldset id="field_10_158" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>QUALIFICATION</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_158'><div class='gchoice gchoice_10_158_1'> <input class='gfield-choice-input' name='input_158.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_10_158_1' /> <label for='choice_10_158_1' id='label_10_158_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_10_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_10_7' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_10_3' class='gform_page' data-js='page-field-id-7' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_10_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_10_9" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h3 style="text-align:center">APPENDIX TO SURGICAL INFORMED CONSENT</h3></div><div id="field_10_122" class="gfield gfield--type-html gfield--in
226put-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions, including wisdom teeth and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.</p> </div><div id="field_10_124" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p class="flashit" style="font-weight:bold;color:#df316b;font-size:16px">IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST.</p> <p>If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email <a href="mailto:[email protected]"><b>[email protected]</b></a> </p> </div><fieldset id="field_10_125" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>APPENDIX TO SURGICAL INFORMED CONSENT</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_125'><div class='gchoice gchoice_10_125_1'> <input class='gfield-choice-input' name='input_125.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_10_125_1' /> <label for='choice_10_125_1' id='label_10_125_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_10_15' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_10_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_10_4' class='gform_page' data-js='page-field-id-15' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_10_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_10_16" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p><b>Ontario’s Narcotics Strategy</b></p> <p><b>List Of Approved Forms Of Identification</b></p> <p> </p><ul> <li>Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications.</li> <li>Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else.</li> </ul><p></p> <p>The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed.</p> <p>Below is a list of forms of identification that a person can present to a prescriber or dispenser: </p><ul> <li>Ontario Health Card or other health card issued by a Province or Territory in Canada</li> <li>Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction)</li> <li>Ontario Photo Card</li> <li>Birth Certificate from a Canadian province or territory</li> <li>Government-issued Employee Identification Card</li> <li>Ontario Outdoors Card</li> <li>BYID (age of majority card)</li> <li>Certificate of Indian Status</li> <li>Valid Passport – Canadian or other country</li> <li>Certificate of Canadian Citizenship</li> <li>Canadian Immigration Identification Card</li> <li>Permanent Resident Card</li> <li>Canadian Immigration Identification Card</li> <li>Old Age Security Identification Card</li> <li>Canadian Armed Forces Identification Card</li> <li>Royal Canadian Mounted Police/Provincial/Municipal Police Identification</li> <li>Firearms Possession and Acquisition Licence</li> </ul> <p></p></div><fieldset id="field_10_60" class="gfield gfield--type-checkbox gfield--type-choice gfield--in
226put-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>Ontario’s Narcotics Strategy</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_60'><div class='gchoice gchoice_10_60_1'> <input class='gfield-choice-input' name='input_60.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_10_60_1' /> <label for='choice_10_60_1' id='label_10_60_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_10_18' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_10_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_10_5' class='gform_page' data-js='page-field-id-18' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_10_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_10_19" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>POST-OPERATIVE INSTRUCTIONS</h5> <h5 style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></h5> <p style="text-align:center">PLEASE READ THESE INSTRUCTIONS CAREFULLY. Sometimes the after effects of oral surgery are quite minimal, so not all of these instructions may apply to you. Common sense will dictate what you should do. However, when in doubt, follow these guidelines or call us for advice.</p> <p style="text-align:center">DAY OF SURGERY (FIRST 24 HRS)</p> <p style="text-align:center">AND DAYS 2-7</p> <h5>FIRST HOUR</h5> <p>Bite down gently but firmly on the gauze packs that have been placed on the surgical sites, making sure they remain in place. Do not change them for the first 30 minutes unless the bleeding is not being controlled. If active bleeding persists after 30 minutes, place enough new gauze to obtain pressure over the surgical site for another 30 minutes. The gauze may be changed as necessary and may be dampened for more comfortable positioning. Do not disturb the surgical area today.NO RINSING, WHATSOEVER, DURING THIS PHASE. DO NOT SMOKE. Smoking increases the risk of dry socket dramatically.</p> <h5>OOZING/BLEEDING</h5> <p>It’s normal to have your saliva stained with blood for a few days. There may also be some slight oozing. If this persists, place fresh gauze over the area and bite down for 30-60 minutes. Bleeding should never be severe. If it is, it usually means the gauze packs are placed between your teeth and not over the surgical sites. Try to reposition them. If this doesn’t work substitute a moistened tea bag wrapped in moist gauze for 30-60 minutes. Do not sleep with gauze in your mouth.When sleeping use an old pillow and place some towels around your head to protect your bedding. If bleeding remains uncontrolled please call us.</p> <h5>SWELLING</h5> <p>Often there is swelling/bruising associated with oral surgery. Swelling is a normal response to trauma. It is not the same as infection. If you are swollen this does not mean you are infected. You can minimize this by using an ice pack applied to the face adjacent to the surgical site. The ice should be applied for a 10 minutes per side every hour over a 24-48 hour period. After the first 24-48 hours, stop icing the area. Do not use ice packs while sleeping. Despite icing the area, swelling will still occur. After 48 hours, apply a warm moist compress for 10-15 min of several times a day for balance of the week. Swelling usually increases over a 72 hour period. Therefore you will appear more swollen on the 3rd day than the 2nd day. After 72 hours, swelling starts to slowly subside and is mostly gone by the 7th day.</p> <h5>RINSING</h5> <p>After the first 48 hours have elapsed you may stop icing the area. At this time start with warm salt water rinse. Place a teaspoon of salt in a glass of warm water. Gently swish it around your mouth 2-3 times a day for the next 7-10 days. Do not spit out the rinse. Let it fall out of your mouth. Spitting exerts a force on the healing clot and can slow down healing and promote bleeding. Do not use mouthwash for the first 7 days unless prescribed by the dentist. Also you may brush in the area unaffected by the surgery butleave the surgical areas alone for 7 days. After that you may gently clean around the area although swelling and soreness may not permit you to do so. In time, you will be able to return to proper oral hygiene care.</p> <h5>PAIN</h5> <p>Unfortunately oral surgery is usually accompanied by some degree of discomfort. You may have been given some pain medication prior to the start of your procedure. It is important to follow the instructions with pain medication as it is easier to “stay ahead of the pain rather than trying to catch up to it.” If you take the first pain pill before the local anesthetic has worn off you will be able to manage the discomfort better.</p> <h5>INFECTION</h5> <p>Unless you present with infection you usually don’t develop an infection in the first few days. Antibiotics are prescribed to either help prevent infections from developing or to treat an infection that is present. Not all procedures require an antibiotic. There is a decrease in effectiveness of birth control medication when taking antibiotics. 
226Consult your physician for advice on additional birth control measures. Slightly elevated temperature may occur for reasons other than infection. Be sure to drink lots of fluids: 1.5-2 liters /day.</p> <h5>DIET</h5> <p>Soft food is the dietary choice for the first few days. Ice cream, Jell-O, pudding, mashed potatoes, soups, pasta, or baby food are good choices. Avoid foods like nuts, popcorn, and rice as they tend to get stuck in the socket areas. Drinks like ENSURE or BOOST are good supplements as well. <b>DO NOT USE A STRAW OR DRINK FROM A BOTTLE</b> for the first 2-3 days. This can exert a force on the blood clot and slow down healing and promote bleeding. Use a spoon or a cup. After the fourth day you can progress to solid foods at you own pace. It is important to eat as you will feel better and heal faster. If you are diabetic, maintain you normal eating habits as much as possible and consult your physician regarding your insulin schedule.</p> <h5>STITCHES</h5> <p>You may have had some stitches placed. They will dissolve on their own in 5-7 days.Not all surgical sites require stitches.If a stitch comes out it is of no concern provided there is no excessive bleeding.</p> <h5>SMOKING</h5> <p>Do not smoke!It is advisable not to smoke for at least 7days.</p> <h5>SYRINGE</h5> <p>You will be given an irrigating syringe at your appointment. Fill a cup with salt water and then fill the syringe. Gently place it in the LOWER SOCKET ONLY and irrigate it 2-3 times. Do this after each meal over the next three to four weeks until the sockets close up. <b>DO NOT USE THE SYRINGE UNTIL 5 DAYS AFTER YOUR SURGERY!</b></p> <h5>REST</h5> <p>You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved.</p> <h5>SHOULD YOU BE UNABLE TO REACH ME IN AN EMERGENCY, GO TO THE NEAREST EMERGENCY ROOM</h5> <h5 style="text-align:center">DR. BRIAN KUMER<br /><a href="tel:+4166050008">(416) 605-0008</a></h5></div><fieldset id="field_10_61" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label gfield_label_before_complex'><span class='gform-field-label__text'>POST-OPERATIVE INSTRUCTIONS</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_61'><div class='gchoice gchoice_10_61_1'> <input class='gfield-choice-input' name='input_61.1' type='checkbox' value='I acknowledge that I have read this document' id='choice_10_61_1' /> <label for='choice_10_61_1' id='label_10_61_1' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I have read this document</label> </div></div></div></fieldset></div> </div> <div class='gform-page-footer gform_page_footer top_label'> <button type='button' id='gform_previous_button_10_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous'>Previous</button> <button type='button' id='gform_next_button_10_21' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next'>Next</button> </div> </div> <div id='gform_page_10_6' class='gform_page' data-js='page-field-id-21' style='display:none'> <div class='gform_page_fields'> <div id='gform_fields_10_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id="field_10_22" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><h5>MEDICAL HISTORY</h5> <p> The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. </p></div>
226<div id="field_10_23" class="gfield gfield--type-select gfield--input-type-select gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_23'><span class='gform-field-label__text'>Sex:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_10_23' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='Male'>Male</option><option value='Female'>Female</option><option value='Other'>Other</option></select></div></div><div id="field_10_24" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_24'><span class='gform-field-label__text'>Date (Please add today&#039;s date)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_10_24' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_24' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_10_24' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_10_24' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_10_24' aria-label='Date (Please add today' s date): choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><div id="field_10_137" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_137'><span class='gform-field-label__text'>Patient ID *first 3 letters of your first name and the first 3 letters of your last name:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_10_137' type='text' value='' class='large' placeholder='aaaaaa' aria-required="true" aria-invalid="false" data-mask="aaaaaa" /></div></div><fieldset id="field_10_25" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Date of birth:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div id='input_10_25' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_10_25_1_container'><label for='input_10_25_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month</label><select name='input_25[]' id='input_10_25_1' aria-required='true'><option value=''>Month</option><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option></select></div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_10_25_2_container'><label for='input_10_25_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day</label><select name='input_25[]' id='input_10_25_2' aria-required='true'><option value=''>Day</option><option value='1'>1</option><option value='2'>2</option><option value='3'>
2263</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11'>11</option><option value='12'>12</option><option value='13'>13</option><option value='14'>14</option><option value='15'>15</option><option value='16'>16</option><option value='17'>17</option><option value='18'>18</option><option value='19'>19</option><option value='20'>20</option><option value='21'>21</option><option value='22'>22</option><option value='23'>23</option><option value='24'>24</option><option value='25'>25</option><option value='26'>26</option><option value='27'>27</option><option value='28'>28</option><option value='29'>29</option><option value='30'>30</option><option value='31'>31</option></select></div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_10_25_3_container'><label for='input_10_25_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year</label><select name='input_25[]' id='input_10_25_3' aria-required='true'><option value=''>Year</option><option value='2027'>2027</option><option value='2026'>2026</option><option value='2025'>2025</option><option value='2024'>2024</option><option value='2023'>2023</option><option value='2022'>2022</option><option value='2021'>2021</option><option value='2020'>2020</option><option value='2019'>2019</option><option value='2018'>2018</option><option value='2017'>2017</option><option value='2016'>2016</option><option value='2015'>2015</option><option value='2014'>2014</option><option value='2013'>2013</option><option value='2012'>2012</option><option value='2011'>2011</option><option value='2010'>2010</option><option value='2009'>2009</option><option value='2008'>2008</option><option value='2007'>2007</option><option value='2006'>2006</option><option value='2005'>2005</option><option value='2004'>2004</option><option value='2003'>2003</option><option value='2002'>2002</option><option value='2001'>2001</option><option value='2000'>2000</option><option value='1999'>1999</option><option value='1998'>1998</option><option value='1997'>1997</option><option value='1996'>1996</option><option value='1995'>1995</option><option value='1994'>1994</option><option value='1993'>1993</option><option value='1992'>1992</option><option value='1991'>1991</option><option value='1990'>1990</option><option value='1989'>1989</option><option value='1988'>1988</option><option value='1987'>1987</option><option value='1986'>1986</option><option value='1985'>1985</option><option value='1984'>1984</option><option value='1983'>1983</option><option value='1982'>1982</option><option value='1981'>1981</option><option value='1980'>1980</option><option value='1979'>1979</option><option value='1978'>1978</option><option value='1977'>1977</option><option value='1976'>1976</option><option value='1975'>1975</option><option value='1974'>1974</option><option value='1973'>1973</option><option value='1972'>1972</option><option value='1971'>1971</option><option value='1970'>1970</option><option value='1969'>1969</option><option value='1968'>1968</option><option value='1967'>1967</option><option value='1966'>1966</option><option value='1965'>1965</option><option value='1964'>1964</option><option value='1963'>1963</option><option value='1962'>1962</option><option value='1961'>1961</option><option value='1960'>1960</option><option value='1959'>1959</option><option value='1958'>1958</option><option value='1957'>1957</option><option value='1956'>1956</option><option value='1955'>1955</option><option value='1954'>1954</option><option value='1953'>1953</option><option value='1952'>1952</option><option value='1951'>1951</option><option value='1950'>1950</option><option value='1949'>1949</option><option value='1948'>1948</option><option value='1947'>1947</option><option value='1946'>1946</option><option value='1945'>1945</option><option value='1944'>1944</option><option value='1943'>1943</option><option value='1942'>1942</option><option value='1941'>1941</option><option value='1940'>1940</option><option value='1939'>1939</option><option value='1938'>1938</option><option value='1937'>1937</option><option value='1936'>1936</option><option value='1935'>1935</option><option value='1934'>1934</option><option value='1933'>1933</option><option value='1932'>1932</option><option value='1931'>1931</option><option value='1930'>1930</option><option value='1929'>1929</option><option value='1928'>1928</option><option value='1927'>1927</option><option value='1926'>1926</option><option value='1925'>1925</option><option value='1924'>1924</option><option value='1923'>1923</option><option value='1922'>1922</option><option value='1921'>1921</option><option value='1920'>1920</option></select></div></div></fieldset><div id="field_10_129" class="gfield gfield--type-text gfield--in
226put-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_129'><span class='gform-field-label__text'>What&#039;s your weight (lbs)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_10_129' type='text' value='' class='medium' placeholder='999' aria-required="true" aria-invalid="false" data-mask="999" /></div></div><div id="field_10_143" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>What's your height?</p></div><div id="field_10_144" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_144'><span class='gform-field-label__text'>Feet</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_144' id='input_10_144' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option></select></div></div><div id="field_10_145" class="gfield gfield--type-select gfield--input-type-select gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_145'><span class='gform-field-label__text'>Inches</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_145' id='input_10_145' class='large gfield_select' aria-required="true" aria-invalid="false"><option value='1'>1</option><option value='2'>2</option><option value='3'>3</option><option value='4'>4</option><option value='5'>5</option><option value='6'>6</option><option value='7'>7</option><option value='8'>8</option><option value='9'>9</option><option value='10'>10</option><option value='11.5'>11.5</option></select></div></div><fieldset id="field_10_27" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>1. Are you being treated for any medical condition at the present time or have you been treated within the past year? If so, why?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_27'> <div class='gchoice gchoice_10_27_0'> <input class='gfield-choice-input' name='input_27' type='radio' value='Yes' id='choice_10_27_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_27_0' id='label_10_27_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_27_1'> <input class='gfield-choice-input' name='input_27' type='radio' value='No' id='choice_10_27_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_27_1' id='label_10_27_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_27_2'> <input class='gfield-choice-input' name='input_27' type='radio' value='Not Sure' id='choice_10_27_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_27_2' id='label_10_27_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_28" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_28'><span class='gform-field-label__text'>Explain:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_10_28' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_10_53" class="gfield gfield--type-text gfield--input-type-text gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_53'><span class='gform-field-label__text'>2. When was your last medical checkup?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_10_53' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_10_30" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>3. Has there been ANY change in your general health in the past year?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_30'> <div class='gchoice gchoice_10_30_0'> <input class='gfield-choice-input' name='input_30' type='radio' value='Yes' id='choice_10_30_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_30_0' id='label_10_30_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_30_1'> <input class='gfield-choice-input' name='input_30' type='radio' value='No' id='choice_10_30_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_30_1' id='label_10_30_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_30_2'> <input class='gfield-choice-input' name='input_30' type='radio' value='Not Sure' id='choice_10_30_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_30_2' id='label_10_30_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_149" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_149'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'>
226<input name='input_149' id='input_10_149' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_150" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_150'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_10_150' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_188" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_188'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_10_188' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_189" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_189'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_10_189' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_191" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_191'><span class='gform-field-label__text'>When did you last have a complete physical exam?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_10_191' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_190" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_190'><span class='gform-field-label__text'>How often do you see your family doctor or specialist?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_10_190' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><div id="field_10_133" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>4. Do you take ANY <strong>PRESCRIPTION</strong> medications (including puffers and birth control pills)? Do you use more than one pharmacy? If yes, provide Pharmacy name + phone number of <strong>ALL</strong> pharmacies you use.</p></div><fieldset id="field_10_36" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>4. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)? If yes provide Pharmacy name + number of ALL pharmacies you use.</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_36'> <div class='gchoice gchoice_10_36_0'> <input class='gfield-choice-input' name='input_36' type='radio' value='Yes' id='choice_10_36_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_36_0' id='label_10_36_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_36_1'> <input class='gfield-choice-input' name='input_36' type='radio' value='No' id='choice_10_36_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_36_1' id='label_10_36_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_10_142" class="gfield gfield--type-list gfield--input-type-list gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Name of Pharmacy &amp; Phone Number:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_list ginput_list '><div class='gfield_list gfield_list_container'><div class="gfield_list_groups"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_142_cell1 gform-grid-col'><input aria-invalid='false' aria-required="true" aria-label='Name of Pharmacy &amp; Phone Number:, Row 1' data-aria-label-template='Name of Pharmacy &amp; Phone Number:, Row {0}' type='text' name='input_142[]' value='' /></div><div class='gfield_list_icons gform-grid-col'> <button type='button' aria-label='Add another row' onclick='gformAddListItem(this, 0)' class="add_list_item nitro-lazy">Add</button> <button type='button' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style="visibility:hidden" class="delete_list_item nitro-lazy">Remove</button></div></div></div></div></div></fieldset><div id="field_10_139" class="gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible">5. Are you taking ANY <strong>NON-PRESCRIPTION</strong> medication (including herbal remedies or vitamins)?</div><fieldset id="field_10_32" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>5. Are you taking any non-prescription drugs or herbal supplements of any kind?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_32'> <div class='gchoice gchoice_10_32_0'> <input class='gfield-choice-input' name='input_32' type='radio' value='Yes' id='choice_10_32_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_32_0' id='label_10_32_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_32_1'> <input class='gfield-choice-input' name='input_32' type='radio' value='No' id='choice_10_32_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_32_1' id='label_10_32_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_10_153" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_153'><span class='gform-field-label__text'>Please List:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_10_153' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_10_34" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>6. Are you allergic to any medications?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_34'> <div class='gchoice gchoice_10_34_0'> <input class='gfield-choice-input' name='input_34' type='radio' value='Yes' id='choice_10_34_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_34_0' id='label_10_34_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_34_1'> <input class='gfield-choice-input' name='input_34' type='radio' value='No' id='choice_10_34_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_34_1' id='label_10_34_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_34_2'> <input class='gfield-choice-input' name='input_34' type='radio' value='Not Sure' id='choice_10_34_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_34_2' id='label_10_34_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_154" class="gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_154'><span class='gform-field-label__text'>Please list the medications that you are allergic to:</span></label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_10_154' type='text' value='' class='large' aria-invalid="false" /></div></div><fieldset id="field_10_155" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>What happened?</span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_155'> <div class='gchoice gchoice_10_155_0'> <input class='gfield-choice-input' name='input_155' type='radio' value='Rash' id='choice_10_155_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_155_0' id='label_10_155_0' class='gform-field-label gform-field-label--type-inline'>Rash</label> </div> <div class='gchoice gchoice_10_155_1'> <input class='gfield-choice-input' name='input_155' type='radio' value='Breathing problems/Wheezing' id='choice_10_155_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_155_1' id='label_10_155_1' class='gform-field-label gform-field-label--type-inline'>Breathing problems/Wheezing</label> </div> <div class='gchoice gchoice_10_155_2'> <input class='gfield-choice-input' name='input_155' type='radio' value='Swelling' id='choice_10_155_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_155_2' id='label_10_155_2' class='gform-field-label gform-field-label--type-inline'>Swelling</label> </div> <div class='gchoice gchoice_10_155_3'> <input class='gfield-choice-input' name='input_155' type='radio' value='Other' id='choice_10_155_3' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_155_3' id='label_10_155_3' class='gform-field-label gform-field-label--type-inline'>Other</label> </div></div></div></fieldset><div id="field_10_156" class="gfield gfield--type-text gfield--in
226put-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_156'><span class='gform-field-label__text'>Untitled</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_10_156' type='text' value='' class='large' aria-required="true" aria-invalid="false" /></div></div><fieldset id="field_10_134" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>7. Do you take any medications for Osteoporosis? (examples Risedronate, Prolia, etc.)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_134'> <div class='gchoice gchoice_10_134_0'> <input class='gfield-choice-input' name='input_134' type='radio' value='Yes' id='choice_10_134_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_134_0' id='label_10_134_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_134_1'> <input class='gfield-choice-input' name='input_134' type='radio' value='No' id='choice_10_134_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_134_1' id='label_10_134_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_134_2'> <input class='gfield-choice-input' name='input_134' type='radio' value='Not Sure' id='choice_10_134_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_134_2' id='label_10_134_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_187" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_187'><span class='gform-field-label__text'>If Prolia, date of last injection:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_10_187' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_187' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_10_187' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_10_187' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_10_187' aria-label='If Prolia, date of last injection:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_10_136" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>8. Do you take 81 mg ASA, daily?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_136'> <div class='gchoice gchoice_10_136_0'> <input class='gfield-choice-input' name='input_136' type='radio' value='Yes' id='choice_10_136_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_136_0' id='label_10_136_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_136_1'> <input class='gfield-choice-input' name='input_136' type='radio' value='No' id='choice_10_136_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_136_1' id='label_10_136_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_136_2'> <input class='gfield-choice-input' name='input_136' type='radio' value='Not Sure' id='choice_10_136_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_136_2' id='label_10_136_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_197" class="gfield gfield--type-html gfield--in
226put-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><span style="font-size:20px;font-weight:700">DO NOT STOP YOUR DAILY ASA</span></div><fieldset id="field_10_37" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>9. Do you have or have you ever had asthma?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_37'> <div class='gchoice gchoice_10_37_0'> <input class='gfield-choice-input' name='input_37' type='radio' value='Yes' id='choice_10_37_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_37_0' id='label_10_37_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_37_1'> <input class='gfield-choice-input' name='input_37' type='radio' value='No' id='choice_10_37_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_37_1' id='label_10_37_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_37_2'> <input class='gfield-choice-input' name='input_37' type='radio' value='Not Sure' id='choice_10_37_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_37_2' id='label_10_37_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_38" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>10. Do you have or have you ever had any heart or blood pressure problems?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_38'> <div class='gchoice gchoice_10_38_0'> <input class='gfield-choice-input' name='input_38' type='radio' value='Yes' id='choice_10_38_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_38_0' id='label_10_38_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_38_1'> <input class='gfield-choice-input' name='input_38' type='radio' value='No' id='choice_10_38_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_38_1' id='label_10_38_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_38_2'> <input class='gfield-choice-input' name='input_38' type='radio' value='Not Sure' id='choice_10_38_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_38_2' id='label_10_38_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_39" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>11. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_39'> <div class='gchoice gchoice_10_39_0'>
226 <input class='gfield-choice-input' name='input_39' type='radio' value='Yes' id='choice_10_39_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_39_0' id='label_10_39_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_39_1'> <input class='gfield-choice-input' name='input_39' type='radio' value='No' id='choice_10_39_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_39_1' id='label_10_39_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_39_2'> <input class='gfield-choice-input' name='input_39' type='radio' value='Not Sure' id='choice_10_39_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_39_2' id='label_10_39_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_40" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>12. Do you have a prosthetic or artificial joint?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_40'> <div class='gchoice gchoice_10_40_0'> <input class='gfield-choice-input' name='input_40' type='radio' value='Yes' id='choice_10_40_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_40_0' id='label_10_40_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_40_1'> <input class='gfield-choice-input' name='input_40' type='radio' value='No' id='choice_10_40_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_40_1' id='label_10_40_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><fieldset id="field_10_41" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>13. Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_41'> <div class='gchoice gchoice_10_41_0'> <input class='gfield-choice-input' name='input_41' type='radio' value='Yes' id='choice_10_41_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_41_0' id='label_10_41_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_41_1'> <input class='gfield-choice-input' name='input_41' type='radio' value='No' id='choice_10_41_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_41_1' id='label_10_41_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_41_2'> <input class='gfield-choice-input' name='input_41' type='radio' value='Not Sure' id='choice_10_41_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_41_2' id='label_10_41_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_42" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>14. Have you ever had hepatitis, jaundice or liver disease?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_42'> <div class='gchoice gchoice_10_42_0'> <input class='gfield-choice-input' name='input_42' type='radio' value='Yes' id='choice_10_42_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_42_0' id='label_10_42_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_42_1'> <input class='gfield-choice-input' name='input_42' type='radio' value='No' id='choice_10_42_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_42_1' id='label_10_42_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_42_2'> <input class='gfield-choice-input' name='input_42' type='radio' value='Not Sure' id='choice_10_42_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_42_2' id='label_10_42_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_43" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>15. Do you have a bleeding problem or bleeding disorder?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_43'> <div class='gchoice gchoice_10_43_0'> <input class='gfield-choice-input' name='input_43' type='radio' value='Yes' id='choice_10_43_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_43_0' id='label_10_43_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_43_1'> <input class='gfield-choice-input' name='input_43' type='radio' value='No' id='choice_10_43_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_43_1' id='label_10_43_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_43_2'> <input class='gfield-choice-input' name='input_43' type='radio' value='Not Sure' id='choice_10_43_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_43_2' id='label_10_43_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_44" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>16. Have you ever been hospitalized for any illnesses or operations?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_44'> <div class='gchoice gchoice_10_44_0'> <input class='gfield-choice-input' name='input_44' type='radio' value='Yes' id='choice_10_44_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_44_0' id='label_10_44_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_44_1'> <input class='gfield-choice-input' name='input_44' type='radio' value='No' id='choice_10_44_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_44_1' id='label_10_44_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div></div></div></fieldset><div id="field_10_45" class="gfield gfield--type-textarea gfield--input-type-textarea gf_color field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_45'><span class='gform-field-label__text'>Explain:</span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_10_45' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></div><div id="field_10_78" class="gfield gfield--type-html gfield--input-type-html gf_color gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><p>17. Do you have or have you ever had any of the following? </p></div><fieldset id="field_10_46" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart murmur:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_46'> <div class='gchoice gchoice_10_46_0'> <input class='gfield-choice-input' name='input_46' type='radio' value='Yes' id='choice_10_46_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_46_0' id='label_10_46_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_46_1'> <input class='gfield-choice-input' name='input_46' type='radio' value='No' id='choice_10_46_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_46_1' id='label_10_46_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_46_2'> <input class='gfield-choice-input' name='input_46' type='radio' value='Not Sure' id='choice_10_46_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_46_2' id='label_10_46_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_80" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart attack:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_80'> <div class='gchoice gchoice_10_80_0'> <input class='gfield-choice-input' name='input_80' type='radio' value='Yes' id='choice_10_80_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_80_0' id='label_10_80_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_80_1'> <input class='gfield-choice-input' name='input_80' type='radio' value='No' id='choice_10_80_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_80_1' id='label_10_80_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_80_2'> <input class='gfield-choice-input' name='input_80' type='radio' value='Not Sure' id='choice_10_80_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_80_2' id='label_10_80_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_81" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Chest pain or angina:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_81'> <div class='gchoice gchoice_10_81_0'> <input class='gfield-choice-input' name='input_81' type='radio' value='Yes' id='choice_10_81_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_81_0' id='label_10_81_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_81_1'> <input class='gfield-choice-input' name='input_81' type='radio' value='No' id='choice_10_81_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_81_1' id='label_10_81_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_81_2'> <input class='gfield-choice-input' name='input_81' type='radio' value='Not Sure' id='choice_10_81_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_81_2' id='label_10_81_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_82" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shortness of breath lying down:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_82'> <div class='gchoice gchoice_10_82_0'> <input class='gfield-choice-input' name='input_82' type='radio' value='Yes' id='choice_10_82_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_82_0' id='label_10_82_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_82_1'> <input class='gfield-choice-input' name='input_82' type='radio' value='No' id='choice_10_82_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_82_1' id='label_10_82_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_82_2'> <input class='gfield-choice-input' name='input_82' type='radio' value='Not Sure' id='choice_10_82_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_82_2' id='label_10_82_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_83" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Swollen ankles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_83'> <div class='gchoice gchoice_10_83_0'> <input class='gfield-choice-input' name='input_83' type='radio' value='Yes' id='choice_10_83_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_83_0' id='label_10_83_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_83_1'> <input class='gfield-choice-input' name='input_83' type='radio' value='No' id='choice_10_83_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_83_1' id='label_10_83_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_83_2'> <input class='gfield-choice-input' name='input_83' type='radio' value='Not Sure' id='choice_10_83_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_83_2' id='label_10_83_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_84" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Heart pacemaker/defibrillator:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_84'> <div class='gchoice gchoice_10_84_0'> <input class='gfield-choice-input' name='input_84' type='radio' value='Yes' id='choice_10_84_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_84_0' id='label_10_84_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_84_1'> <input class='gfield-choice-input' name='input_84' type='radio' value='No' id='choice_10_84_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_84_1' id='label_10_84_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_84_2'> <input class='gfield-choice-input' name='input_84' type='radio' value='Not Sure' id='choice_10_84_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_84_2' id='label_10_84_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_85" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Irregular heart beat/arrhythmia:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_85'> <div class='gchoice gchoice_10_85_0'> <input class='gfield-choice-input' name='input_85' type='radio' value='Yes' id='choice_10_85_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_85_0' id='label_10_85_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_85_1'> <input class='gfield-choice-input' name='input_85' type='radio' value='No' id='choice_10_85_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_85_1' id='label_10_85_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_85_2'> <input class='gfield-choice-input' name='input_85' type='radio' value='Not Sure' id='choice_10_85_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_85_2' id='label_10_85_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_86" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>High blood pressure:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_86'> <div class='gchoice gchoice_10_86_0'> <input class='gfield-choice-input' name='input_86' type='radio' value='Yes' id='choice_10_86_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_86_0' id='label_10_86_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_86_1'> <input class='gfield-choice-input' name='input_86' type='radio' value='No' id='choice_10_86_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_86_1' id='label_10_86_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_86_2'> <input class='gfield-choice-input' name='input_86' type='radio' value='Not Sure' id='choice_10_86_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_86_2' id='label_10_86_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_138" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Shingles:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_138'> <div class='gchoice gchoice_10_138_0'> <input class='gfield-choice-input' name='input_138' type='radio' value='Yes' id='choice_10_138_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_138_0' id='label_10_138_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_138_1'> <input class='gfield-choice-input' name='input_138' type='radio' value='No' id='choice_10_138_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_138_1' id='label_10_138_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_138_2'> <input class='gfield-choice-input' name='input_138' type='radio' value='Not Sure' id='choice_10_138_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_138_2' id='label_10_138_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_87" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Congenital heart disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_87'> <div class='gchoice gchoice_10_87_0'> <input class='gfield-choice-input' name='input_87' type='radio' value='Yes' id='choice_10_87_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_87_0' id='label_10_87_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_87_1'> <input class='gfield-choice-input' name='input_87' type='radio' value='No' id='choice_10_87_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_87_1' id='label_10_87_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_87_2'> <input class='gfield-choice-input' name='input_87' type='radio' value='Not Sure' id='choice_10_87_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_87_2' id='label_10_87_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_88" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Damaged/abnormal heart valves:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_88'> <div class='gchoice gchoice_10_88_0'> <input class='gfield-choice-input' name='input_88' type='radio' value='Yes' id='choice_10_88_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_88_0' id='label_10_88_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_88_1'> <input class='gfield-choice-input' name='input_88' type='radio' value='No' id='choice_10_88_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_88_1' id='label_10_88_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_88_2'> <input class='gfield-choice-input' name='input_88' type='radio' value='Not Sure' id='choice_10_88_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_88_2' id='label_10_88_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_89" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Rheumatic fever:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_89'> <div class='gchoice gchoice_10_89_0'> <input class='gfield-choice-input' name='input_89' type='radio' value='Yes' id='choice_10_89_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_89_0' id='label_10_89_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_89_1'> <input class='gfield-choice-input' name='input_89' type='radio' value='No' id='choice_10_89_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_89_1' id='label_10_89_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_89_2'> <input class='gfield-choice-input' name='input_89' type='radio' value='Not Sure' id='choice_10_89_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_89_2' id='label_10_89_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_90" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Kidney disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_90'> <div class='gchoice gchoice_10_90_0'> <input class='gfield-choice-input' name='input_90' type='radio' value='Yes' id='choice_10_90_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_90_0' id='label_10_90_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_90_1'> <input class='gfield-choice-input' name='input_90' type='radio' value='No' id='choice_10_90_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_90_1' id='label_10_90_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_90_2'> <input class='gfield-choice-input' name='input_90' type='radio' value='Not Sure' id='choice_10_90_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_90_2' id='label_10_90_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_91" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>HIV, AIDS or STD:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_91'> <div class='gchoice gchoice_10_91_0'> <input class='gfield-choice-input' name='input_91' type='radio' value='Yes' id='choice_10_91_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_91_0' id='label_10_91_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_91_1'> <input class='gfield-choice-input' name='input_91' type='radio' value='No' id='choice_10_91_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_91_1' id='label_10_91_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_91_2'> <input class='gfield-choice-input' name='input_91' type='radio' value='Not Sure' id='choice_10_91_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_91_2' id='label_10_91_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_94" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cancer / Chemotherapy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_94'> <div class='gchoice gchoice_10_94_0'> <input class='gfield-choice-input' name='input_94' type='radio' value='Yes' id='choice_10_94_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_94_0' id='label_10_94_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_94_1'> <input class='gfield-choice-input' name='input_94' type='radio' value='No' id='choice_10_94_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_94_1' id='label_10_94_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_94_2'> <input class='gfield-choice-input' name='input_94' type='radio' value='Not Sure' id='choice_10_94_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_94_2' id='label_10_94_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_95" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been screened for Sleep Apnea?:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_95'> <div class='gchoice gchoice_10_95_0'> <input class='gfield-choice-input' name='input_95' type='radio' value='Yes' id='choice_10_95_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_95_0' id='label_10_95_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_95_1'> <input class='gfield-choice-input' name='input_95' type='radio' value='No' id='choice_10_95_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_95_1' id='label_10_95_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_95_2'> <input class='gfield-choice-input' name='input_95' type='radio' value='Not Sure' id='choice_10_95_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_95_2' id='label_10_95_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_157" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gfield--width-full gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Have you been diagnosed with Sleep Apnea?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_157'> <div class='gchoice gchoice_10_157_0'> <input class='gfield-choice-input' name='input_157' type='radio' value='Yes' id='choice_10_157_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_157_0' id='label_10_157_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_157_1'> <input class='gfield-choice-input' name='input_157' type='radio' value='No' id='choice_10_157_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_157_1' id='label_10_157_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_157_2'> <input class='gfield-choice-input' name='input_157' type='radio' value='Not Sure' id='choice_10_157_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_157_2' id='label_10_157_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_96" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Asthma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_96'> <div class='gchoice gchoice_10_96_0'> <input class='gfield-choice-input' name='input_96' type='radio' value='Yes' id='choice_10_96_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_96_0' id='label_10_96_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_96_1'> <input class='gfield-choice-input' name='input_96' type='radio' value='No' id='choice_10_96_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_96_1' id='label_10_96_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_96_2'> <input class='gfield-choice-input' name='input_96' type='radio' value='Not Sure' id='choice_10_96_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_96_2' id='label_10_96_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_97" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Emphysema / Bronchitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_97'> <div class='gchoice gchoice_10_97_0'> <input class='gfield-choice-input' name='input_97' type='radio' value='Yes' id='choice_10_97_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_97_0' id='label_10_97_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_97_1'> <input class='gfield-choice-input' name='input_97' type='radio' value='No' id='choice_10_97_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_97_1' id='label_10_97_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_97_2'> <input class='gfield-choice-input' name='input_97' type='radio' value='Not Sure' id='choice_10_97_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_97_2' id='label_10_97_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_98" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cystic fibrosis / Tuberculosis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_98'> <div class='gchoice gchoice_10_98_0'> <input class='gfield-choice-input' name='input_98' type='radio' value='Yes' id='choice_10_98_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_98_0' id='label_10_98_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_98_1'> <input class='gfield-choice-input' name='input_98' type='radio' value='No' id='choice_10_98_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_98_1' id='label_10_98_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_98_2'> <input class='gfield-choice-input' name='input_98' type='radio' value='Not Sure' id='choice_10_98_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_98_2' id='label_10_98_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_99" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Epilepsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_99'> <div class='gchoice gchoice_10_99_0'> <input class='gfield-choice-input' name='input_99' type='radio' value='Yes' id='choice_10_99_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_99_0' id='label_10_99_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_99_1'> <input class='gfield-choice-input' name='input_99' type='radio' value='No' id='choice_10_99_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_99_1' id='label_10_99_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_99_2'> <input class='gfield-choice-input' name='input_99' type='radio' value='Not Sure' id='choice_10_99_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_99_2' id='label_10_99_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_100" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stroke:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_100'> <div class='gchoice gchoice_10_100_0'> <input class='gfield-choice-input' name='input_100' type='radio' value='Yes' id='choice_10_100_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_100_0' id='label_10_100_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_100_1'> <input class='gfield-choice-input' name='input_100' type='radio' value='No' id='choice_10_100_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_100_1' id='label_10_100_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_100_2'> <input class='gfield-choice-input' name='input_100' type='radio' value='Not Sure' id='choice_10_100_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_100_2' id='label_10_100_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_101" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Fainting spells, dizziness:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_101'> <div class='gchoice gchoice_10_101_0'> <input class='gfield-choice-input' name='input_101' type='radio' value='Yes' id='choice_10_101_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_101_0' id='label_10_101_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_101_1'> <input class='gfield-choice-input' name='input_101' type='radio' value='No' id='choice_10_101_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_101_1' id='label_10_101_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_101_2'> <input class='gfield-choice-input' name='input_101' type='radio' value='Not Sure' id='choice_10_101_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_101_2' id='label_10_101_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_102" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Diabetes:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_102'> <div class='gchoice gchoice_10_102_0'> <input class='gfield-choice-input' name='input_102' type='radio' value='Yes' id='choice_10_102_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_102_0' id='label_10_102_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_102_1'> <input class='gfield-choice-input' name='input_102' type='radio' value='No' id='choice_10_102_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_102_1' id='label_10_102_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_102_2'> <input class='gfield-choice-input' name='input_102' type='radio' value='Not Sure' id='choice_10_102_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_102_2' id='label_10_102_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_103" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Thyroid Disease:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_103'> <div class='gchoice gchoice_10_103_0'> <input class='gfield-choice-input' name='input_103' type='radio' value='Yes' id='choice_10_103_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_103_0' id='label_10_103_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_103_1'> <input class='gfield-choice-input' name='input_103' type='radio' value='No' id='choice_10_103_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_103_1' id='label_10_103_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_103_2'> <input class='gfield-choice-input' name='input_103' type='radio' value='Not Sure' id='choice_10_103_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_103_2' id='label_10_103_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_104" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Adrenal gland disorder:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_104'> <div class='gchoice gchoice_10_104_0'> <input class='gfield-choice-input' name='input_104' type='radio' value='Yes' id='choice_10_104_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_104_0' id='label_10_104_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_104_1'> <input class='gfield-choice-input' name='input_104' type='radio' value='No' id='choice_10_104_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_104_1' id='label_10_104_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_104_2'> <input class='gfield-choice-input' name='input_104' type='radio' value='Not Sure' id='choice_10_104_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_104_2' id='label_10_104_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_105" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Hepatitis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_105'> <div class='gchoice gchoice_10_105_0'> <input class='gfield-choice-input' name='input_105' type='radio' value='Yes' id='choice_10_105_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_105_0' id='label_10_105_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_105_1'> <input class='gfield-choice-input' name='input_105' type='radio' value='No' id='choice_10_105_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_105_1' id='label_10_105_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_105_2'> <input class='gfield-choice-input' name='input_105' type='radio' value='Not Sure' id='choice_10_105_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_105_2' id='label_10_105_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_106" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Liver disease / Jaundice:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_106'> <div class='gchoice gchoice_10_106_0'> <input class='gfield-choice-input' name='input_106' type='radio' value='Yes' id='choice_10_106_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_106_0' id='label_10_106_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_106_1'> <input class='gfield-choice-input' name='input_106' type='radio' value='No' id='choice_10_106_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_106_1' id='label_10_106_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_106_2'> <input class='gfield-choice-input' name='input_106' type='radio' value='Not Sure' id='choice_10_106_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_106_2' id='label_10_106_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_107" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Anemia (including sickle cell):</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_107'> <div class='gchoice gchoice_10_107_0'> <input class='gfield-choice-input' name='input_107' type='radio' value='Yes' id='choice_10_107_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_107_0' id='label_10_107_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_107_1'> <input class='gfield-choice-input' name='input_107' type='radio' value='No' id='choice_10_107_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_107_1' id='label_10_107_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_107_2'> <input class='gfield-choice-input' name='input_107' type='radio' value='Not Sure' id='choice_10_107_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_107_2' id='label_10_107_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_108" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Blood disorders/transfusions:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_108'> <div class='gchoice gchoice_10_108_0'> <input class='gfield-choice-input' name='input_108' type='radio' value='Yes' id='choice_10_108_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_108_0' id='label_10_108_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_108_1'> <input class='gfield-choice-input' name='input_108' type='radio' value='No' id='choice_10_108_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_108_1' id='label_10_108_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_108_2'> <input class='gfield-choice-input' name='input_108' type='radio' value='Not Sure' id='choice_10_108_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_108_2' id='label_10_108_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_109" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bleeding (Coagulation) disorders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_109'> <div class='gchoice gchoice_10_109_0'> <input class='gfield-choice-input' name='input_109' type='radio' value='Yes' id='choice_10_109_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_109_0' id='label_10_109_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_109_1'> <input class='gfield-choice-input' name='input_109' type='radio' value='No' id='choice_10_109_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_109_1' id='label_10_109_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_109_2'> <input class='gfield-choice-input' name='input_109' type='radio' value='Not Sure' id='choice_10_109_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_109_2' id='label_10_109_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_110" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Stomach ulcers/ Acid Reflux:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_110'> <div class='gchoice gchoice_10_110_0'> <input class='gfield-choice-input' name='input_110' type='radio' value='Yes' id='choice_10_110_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_110_0' id='label_10_110_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_110_1'> <input class='gfield-choice-input' name='input_110' type='radio' value='No' id='choice_10_110_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_110_1' id='label_10_110_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_110_2'> <input class='gfield-choice-input' name='input_110' type='radio' value='Not Sure' id='choice_10_110_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_110_2' id='label_10_110_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_111" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Bone, joint, or muscle problems:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_111'> <div class='gchoice gchoice_10_111_0'> <input class='gfield-choice-input' name='input_111' type='radio' value='Yes' id='choice_10_111_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_111_0' id='label_10_111_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_111_1'> <input class='gfield-choice-input' name='input_111' type='radio' value='No' id='choice_10_111_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_111_1' id='label_10_111_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_111_2'> <input class='gfield-choice-input' name='input_111' type='radio' value='Not Sure' id='choice_10_111_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_111_2' id='label_10_111_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_112" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Artificial joints - hips, knees, shoulders:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_112'> <div class='gchoice gchoice_10_112_0'> <input class='gfield-choice-input' name='input_112' type='radio' value='Yes' id='choice_10_112_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_112_0' id='label_10_112_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_112_1'> <input class='gfield-choice-input' name='input_112' type='radio' value='No' id='choice_10_112_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_112_1' id='label_10_112_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_112_2'> <input class='gfield-choice-input' name='input_112' type='radio' value='Not Sure' id='choice_10_112_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_112_2' id='label_10_112_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_152" class="gfield gfield--type-date gfield--in
226put-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_152'><span class='gform-field-label__text'>Date of replacement:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_10_152' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_152' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_10_152' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_10_152' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_10_152' aria-label='Date of replacement:: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_10_113" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Arthritis:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_113'> <div class='gchoice gchoice_10_113_0'> <input class='gfield-choice-input' name='input_113' type='radio' value='Yes' id='choice_10_113_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_113_0' id='label_10_113_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_113_1'> <input class='gfield-choice-input' name='input_113' type='radio' value='No' id='choice_10_113_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_113_1' id='label_10_113_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_113_2'> <input class='gfield-choice-input' name='input_113' type='radio' value='Not Sure' id='choice_10_113_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_113_2' id='label_10_113_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_114" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Depression / anxiety:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_114'> <div class='gchoice gchoice_10_114_0'> <input class='gfield-choice-input' name='input_114' type='radio' value='Yes' id='choice_10_114_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_114_0' id='label_10_114_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_114_1'> <input class='gfield-choice-input' name='input_114' type='radio' value='No' id='choice_10_114_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_114_1' id='label_10_114_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_114_2'> <input class='gfield-choice-input' name='input_114' type='radio' value='Not Sure' id='choice_10_114_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_114_2' id='label_10_114_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_115" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Vision problems / glaucoma:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_115'> <div class='gchoice gchoice_10_115_0'> <input class='gfield-choice-input' name='input_115' type='radio' value='Yes' id='choice_10_115_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_115_0' id='label_10_115_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_115_1'> <input class='gfield-choice-input' name='input_115' type='radio' value='No' id='choice_10_115_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_115_1' id='label_10_115_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_115_2'> <input class='gfield-choice-input' name='input_115' type='radio' value='Not Sure' id='choice_10_115_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_115_2' id='label_10_115_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_116" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>People with intellectual/cognitive disabilities:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_116'> <div class='gchoice gchoice_10_116_0'> <input class='gfield-choice-input' name='input_116' type='radio' value='Yes' id='choice_10_116_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_116_0' id='label_10_116_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_116_1'> <input class='gfield-choice-input' name='input_116' type='radio' value='No' id='choice_10_116_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_116_1' id='label_10_116_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_116_2'> <input class='gfield-choice-input' name='input_116' type='radio' value='Not Sure' id='choice_10_116_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_116_2' id='label_10_116_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_117" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Cerebral palsy:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_117'> <div class='gchoice gchoice_10_117_0'> <input class='gfield-choice-input' name='input_117' type='radio' value='Yes' id='choice_10_117_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_117_0' id='label_10_117_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_117_1'> <input class='gfield-choice-input' name='input_117' type='radio' value='No' id='choice_10_117_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_117_1' id='label_10_117_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_117_2'> <input class='gfield-choice-input' name='input_117' type='radio' value='Not Sure' id='choice_10_117_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_117_2' id='label_10_117_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_118" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Autism or Down&#039;s syndrome:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_118'> <div class='gchoice gchoice_10_118_0'> <input class='gfield-choice-input' name='input_118' type='radio' value='Yes' id='choice_10_118_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_118_0' id='label_10_118_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_118_1'> <input class='gfield-choice-input' name='input_118' type='radio' value='No' id='choice_10_118_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_118_1' id='label_10_118_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_118_2'> <input class='gfield-choice-input' name='input_118' type='radio' value='Not Sure' id='choice_10_118_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_118_2' id='label_10_118_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_119" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_119'> <div class='gchoice gchoice_10_119_0'> <input class='gfield-choice-input' name='input_119' type='radio' value='Yes' id='choice_10_119_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_119_0' id='label_10_119_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_119_1'> <input class='gfield-choice-input' name='input_119' type='radio' value='No' id='choice_10_119_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_119_1' id='label_10_119_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_119_2'> <input class='gfield-choice-input' name='input_119' type='radio' value='Not Sure' id='choice_10_119_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_119_2' id='label_10_119_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_120" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Are you a nursing mother?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_120'> <div class='gchoice gchoice_10_120_0'> <input class='gfield-choice-input' name='input_120' type='radio' value='Yes' id='choice_10_120_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_120_0' id='label_10_120_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_120_1'> <input class='gfield-choice-input' name='input_120' type='radio' value='No' id='choice_10_120_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_120_1' id='label_10_120_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_120_2'> <input class='gfield-choice-input' name='input_120' type='radio' value='Not Sure' id='choice_10_120_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_120_2' id='label_10_120_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_121" class="gfield gfield--type-radio gfield--type-choice gfield--in
226put-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>Any problems with menstruation?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_121'> <div class='gchoice gchoice_10_121_0'> <input class='gfield-choice-input' name='input_121' type='radio' value='Yes' id='choice_10_121_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_121_0' id='label_10_121_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_121_1'> <input class='gfield-choice-input' name='input_121' type='radio' value='No' id='choice_10_121_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_121_1' id='label_10_121_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_121_2'> <input class='gfield-choice-input' name='input_121' type='radio' value='Not Sure' id='choice_10_121_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_121_2' id='label_10_121_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_48" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>18. Are there any conditions or diseases not listed above that you have or have had?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_48'> <div class='gchoice gchoice_10_48_0'> <input class='gfield-choice-input' name='input_48' type='radio' value='Yes' id='choice_10_48_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_48_0' id='label_10_48_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_48_1'> <input class='gfield-choice-input' name='input_48' type='radio' value='No' id='choice_10_48_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_48_1' id='label_10_48_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_48_2'> <input class='gfield-choice-input' name='input_48' type='radio' value='Not Sure' id='choice_10_48_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_48_2' id='label_10_48_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_126" class="gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_126'><span class='gform-field-label__text'>Explain :</span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_10_126' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_10_49" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>21. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_49'> <div class='gchoice gchoice_10_49_0'> <input class='gfield-choice-input' name='input_49' type='radio' value='Yes' id='choice_10_49_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_49_0' id='label_10_49_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_49_1'> <input class='gfield-choice-input' name='input_49' type='radio' value='No' id='choice_10_49_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_49_1' id='label_10_49_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_49_2'> <input class='gfield-choice-input' name='input_49' type='radio' value='Not Sure' id='choice_10_49_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_49_2' id='label_10_49_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_196" class="gfield gfield--type-textarea gfield--in
226put-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_196'><span class='gform-field-label__text'>Please List:</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_196' id='input_10_196' class='textarea small' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></div><fieldset id="field_10_50" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>22. Do you smoke or chew tobacco products?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_50'> <div class='gchoice gchoice_10_50_0'> <input class='gfield-choice-input' name='input_50' type='radio' value='Yes' id='choice_10_50_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_50_0' id='label_10_50_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_50_1'> <input class='gfield-choice-input' name='input_50' type='radio' value='No' id='choice_10_50_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_50_1' id='label_10_50_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_50_2'> <input class='gfield-choice-input' name='input_50' type='radio' value='Not Sure' id='choice_10_50_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_50_2' id='label_10_50_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><fieldset id="field_10_51" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical"><legend class='gfield_label gform-field-label'><span class='gform-field-label__text'>23. For women only: Are you breastfeeding or pregnant?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_51'> <div class='gchoice gchoice_10_51_0'> <input class='gfield-choice-input' name='input_51' type='radio' value='Yes' id='choice_10_51_0' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_51_0' id='label_10_51_0' class='gform-field-label gform-field-label--type-inline'>Yes</label> </div> <div class='gchoice gchoice_10_51_1'> <input class='gfield-choice-input' name='input_51' type='radio' value='No' id='choice_10_51_1' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_51_1' id='label_10_51_1' class='gform-field-label gform-field-label--type-inline'>No</label> </div> <div class='gchoice gchoice_10_51_2'> <input class='gfield-choice-input' name='input_51' type='radio' value='Not Sure' id='choice_10_51_2' onchange='gformToggleRadioOther( this )' /> <label for='choice_10_51_2' id='label_10_51_2' class='gform-field-label gform-field-label--type-inline'>Not Sure</label> </div></div></div></fieldset><div id="field_10_52" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_color gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><label class='gfield_label gform-field-label' for='input_10_52'><span class='gform-field-label__text'>If pregnant, what is the expected delivery date?</span><span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_date'> <input placeholder='mm/dd/yyyy' id='input_10_52' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon' type='text' name='input_52' value='' aria-invalid="false" aria-required="true" data-mask="99/99/9999" /> <kbd id='keyboardHint_input_10_52' hidden class='down'></kbd> <button type='button' id='datepicker_toggle_input_10_52' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_10_52' aria-label='If pregnant, what is the expected delivery date?: Choose date on calendar'> <span class="gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt" aria-hidden="true"></span> </button> </div></div><fieldset id="field_10_147" class="gfield gfield--type-signature gfield--in
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Line numbers count LF bytes from the start of the resource, as the search results do. Vendor segments are library code the classifier recognised; they are stored but not indexed. Bytes are shown as Latin1 characters, one per byte.