{"id":1773,"date":"2024-05-03T15:33:00","date_gmt":"2024-05-03T19:33:00","guid":{"rendered":"https:\/\/www.adelphi.edu\/education\/community-programs-and-outreach\/human-performance-lab\/application\/"},"modified":"2024-06-25T15:50:59","modified_gmt":"2024-06-25T19:50:59","slug":"application","status":"publish","type":"page","link":"https:\/\/www.adelphi.edu\/education\/community-programs-and-outreach\/human-performance-lab\/application\/","title":{"rendered":"Application"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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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><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/education\/wp-json\/wp\/v2\/pages\/1773#gf_12' data-formid='12' novalidate><input type=\"hidden\" name=\"adelphi_gf_data\" value=\"1:local-9a23b7a5e5384a31717485113d24fc68:1776224769\"><input type=\"hidden\" name=\"adelphi_gf_hmac\" value=\"4aa109676772aff4bded3f2d40213c815cf1c4fe4d8596bb04906dfced6a0153\">\n        <div id='gf_progressbar_wrapper_12' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue 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field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_12_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_13_1_container' >\n                                        <label for='input_12_13_1' id='input_12_13_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_13.1' id='input_12_13_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_12_13_2_container' >\n                                        <label for='input_12_13_2' id='input_12_13_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_13.2' id='input_12_13_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_12_13_3_container' >\n                                    <label for='input_12_13_3' id='input_12_13_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_13.3' id='input_12_13_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_12_13_4_container' >\n                                        <label for='input_12_13_4' id='input_12_13_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_13.4' id='input_12_13_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_12_13_5_container' >\n                                    <label for='input_12_13_5' id='input_12_13_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_13.5' id='input_12_13_5' value=''    aria-required='false'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_12_13_6_container' >\n                                        <label for='input_12_13_6' id='input_12_13_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                        <select name='input_13.6' id='input_12_13_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_12_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_4'>\n\t\t\t<div class='gchoice gchoice_12_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Triathlon'  id='choice_12_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_4_0' id='label_12_4_0' class='gform-field-label gform-field-label--type-inline'>Triathlon<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Running'  id='choice_12_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_4_1' id='label_12_4_1' class='gform-field-label gform-field-label--type-inline'>Running<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_4_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Cycling'  id='choice_12_4_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_4_2' id='label_12_4_2' class='gform-field-label gform-field-label--type-inline'>Cycling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_4_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='gf_other_choice'  id='choice_12_4_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_4_3' id='label_12_4_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_12_4_other' class='gchoice_other_control' name='input_4_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_5\" class=\"gfield gfield--type-select gfield--width-full 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_12_5'>Sport Participation Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_12_5' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select length of time<\/option><option value='Less than 2 years' >Less than 2 years<\/option><option value='2-5 years' >2-5 years<\/option><option value='6-10 years' >6-10 years<\/option><option value='More than 10 years' >More than 10 years<\/option><\/select><\/div><\/div><div id=\"field_12_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Interest in Testing<\/h3><\/div><fieldset id=\"field_12_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Performance and Composition Testing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_6'><div class='gchoice gchoice_12_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Max VO2'  id='choice_12_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_6_1' id='label_12_6_1' class='gform-field-label gform-field-label--type-inline'>Max VO2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='BRICK (Double Max VO2)'  id='choice_12_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_6_2' id='label_12_6_2' class='gform-field-label gform-field-label--type-inline'>BRICK (Double Max VO2)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Resting Metabolic Rate (RMR)'  id='choice_12_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_6_3' id='label_12_6_3' class='gform-field-label gform-field-label--type-inline'>Resting Metabolic Rate (RMR)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Body Composition by Hydrostatic Weighing'  id='choice_12_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_6_4' id='label_12_6_4' class='gform-field-label gform-field-label--type-inline'>Body Composition by Hydrostatic Weighing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='Body Composition by DEXA'  id='choice_12_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_6_5' id='label_12_6_5' class='gform-field-label gform-field-label--type-inline'>Body Composition by DEXA<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_129\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_129'>Reason for Evaluation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_129'>What is your reason for the evaluation?<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_12_129' class='textarea large'  aria-describedby=\"gfield_description_12_129\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_12_19' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_2' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_12_44\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><br \/><\/div><div id=\"field_12_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><fieldset id=\"field_12_12\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Today&#039;s Date<\/legend><div id='input_12_12' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_12_12_1_container'>\n                                            <input type='number' maxlength='2' name='input_12[]' id='input_12_12_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_12_12_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_12_12_2_container'>\n                                            <input type='number' maxlength='2' name='input_12[]' id='input_12_12_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_12_12_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_12_12_3_container'>\n                                            <input type='number' maxlength='4' name='input_12[]' id='input_12_12_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_12_12_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_12_14\" class=\"gfield gfield--type-number gfield--width-half 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_12_14'>Age<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_12_14' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_12_15\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of Birth<\/legend><div id='input_12_15' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_12_15_1_container'>\n                                            <input type='number' maxlength='2' name='input_15[]' id='input_12_15_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_12_15_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_12_15_2_container'>\n                                            <input type='number' maxlength='2' name='input_15[]' id='input_12_15_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_12_15_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_12_15_3_container'>\n                                            <input type='number' maxlength='4' name='input_15[]' id='input_12_15_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_12_15_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_12_18\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_18'>Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_18'>Provide in feet (ft) + inches (in) units of measurement.<\/div><div class='ginput_container ginput_container_number'><input name='input_18' id='input_12_18' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_18\" \/><\/div><\/div><div id=\"field_12_17\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_17'>Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_17'>Provide in pounds (lbs).<\/div><div class='ginput_container ginput_container_number'><input name='input_17' id='input_12_17' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_17\" \/><\/div><\/div><fieldset id=\"field_12_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are Your Taking any Medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_20'>\n\t\t\t<div class='gchoice gchoice_12_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_12_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_20_0' id='label_12_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_12_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_20_1' id='label_12_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_21\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_21'>Name and explain each medication and dose<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_21'>Please include over-the-counter medications as well.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_12_21' class='textarea large'  aria-describedby=\"gfield_description_12_21\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you under the care of a physician?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_22'>\n\t\t\t<div class='gchoice gchoice_12_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_12_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_22_0' id='label_12_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_12_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_22_1' id='label_12_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_23\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_23'>Please explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_12_23' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Recent Symptoms<\/legend><div class='gfield_description' id='gfield_description_12_29'>Please check any of the following you have experienced within the last year.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_29'><div class='gchoice gchoice_12_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Abnormal Blood Lipids'  id='choice_12_29_1'   aria-describedby=\"gfield_description_12_29\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_1' id='label_12_29_1' class='gform-field-label gform-field-label--type-inline'>Abnormal Blood Lipids<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Arthritis'  id='choice_12_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_2' id='label_12_29_2' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Back Pain'  id='choice_12_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_3' id='label_12_29_3' class='gform-field-label gform-field-label--type-inline'>Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Chest Pain'  id='choice_12_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_4' id='label_12_29_4' class='gform-field-label gform-field-label--type-inline'>Chest Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='Cough on Exertion'  id='choice_12_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_5' id='label_12_29_5' class='gform-field-label gform-field-label--type-inline'>Cough on Exertion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='Coughing up Blood'  id='choice_12_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_6' id='label_12_29_6' class='gform-field-label gform-field-label--type-inline'>Coughing up Blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='Fainting'  id='choice_12_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_7' id='label_12_29_7' class='gform-field-label gform-field-label--type-inline'>Fainting<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='Frequent or Severe Headaches'  id='choice_12_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_8' id='label_12_29_8' class='gform-field-label gform-field-label--type-inline'>Frequent or Severe Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.9' type='checkbox'  value='Lightheadedness'  id='choice_12_29_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_9' id='label_12_29_9' class='gform-field-label gform-field-label--type-inline'>Lightheadedness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.11' type='checkbox'  value='Orthopedic Problems'  id='choice_12_29_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_11' id='label_12_29_11' class='gform-field-label gform-field-label--type-inline'>Orthopedic Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.12' type='checkbox'  value='Rapid Heart Beats or Heart Palpitations'  id='choice_12_29_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_12' id='label_12_29_12' class='gform-field-label gform-field-label--type-inline'>Rapid Heart Beats or Heart Palpitations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.13' type='checkbox'  value='Shortness of Breath'  id='choice_12_29_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_13' id='label_12_29_13' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_29_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.14' type='checkbox'  value='Swollen Legs\/Ankles'  id='choice_12_29_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_29_14' id='label_12_29_14' class='gform-field-label gform-field-label--type-inline'>Swollen Legs\/Ankles<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_40\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_40'>Provide additional information about your abnormal blood lipids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_12_40' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_37\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_37'>Provide additional information about your arthritis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_12_37' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_36\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_36'>Provide additional information about your back pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_12_36' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_30\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_30'>Provide additional information about your chest pain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_12_30' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_34\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_34'>Provide additional information about your cough on exertion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_12_34' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_35\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_35'>Provide additional information about your coughing up blood<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_12_35' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_39\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_39'>Provide additional information about your fainting<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_12_39' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_42\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_42'>Provide additional information about  your frequent or severe headaches<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_12_42' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_33\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_33'>Provide additional information about your lightheadedness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_12_33' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_41\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_41'>Provide additional information about your orthopedic problems<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_12_41' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_32\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_32'>Provide additional information about your rapid heart beats or palpitations<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_12_32' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_31\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_31'>Provide additional information about your shortness of breath<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_12_31' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_38\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_38'>Provide additional information about your swollen legs and\/or ankles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_38' id='input_12_38' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever had?<\/legend><div class='gfield_description' id='gfield_description_12_28'>Please check any of the following you have experienced.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_28'><div class='gchoice gchoice_12_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Abnormal Heart Rhythm'  id='choice_12_28_1'   aria-describedby=\"gfield_description_12_28\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_1' id='label_12_28_1' class='gform-field-label gform-field-label--type-inline'>Abnormal Heart Rhythm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Asthma'  id='choice_12_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_2' id='label_12_28_2' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Artery Disease'  id='choice_12_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_3' id='label_12_28_3' class='gform-field-label gform-field-label--type-inline'>Artery Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Chest Discomfort'  id='choice_12_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_4' id='label_12_28_4' class='gform-field-label gform-field-label--type-inline'>Chest Discomfort<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Diabetes'  id='choice_12_28_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_5' id='label_12_28_5' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Epilepsy'  id='choice_12_28_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_6' id='label_12_28_6' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.7' type='checkbox'  value='Gout'  id='choice_12_28_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_7' id='label_12_28_7' class='gform-field-label gform-field-label--type-inline'>Gout<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.8' type='checkbox'  value='Heart Trouble'  id='choice_12_28_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_8' id='label_12_28_8' class='gform-field-label gform-field-label--type-inline'>Heart Trouble<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.9' type='checkbox'  value='Heart Attack'  id='choice_12_28_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_9' id='label_12_28_9' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.11' type='checkbox'  value='High Blood Pressure'  id='choice_12_28_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_11' id='label_12_28_11' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.12' type='checkbox'  value='Hospitalization'  id='choice_12_28_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_12' id='label_12_28_12' class='gform-field-label gform-field-label--type-inline'>Hospitalization<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.13' type='checkbox'  value='Immune Disorders (such as allergies or lupus)'  id='choice_12_28_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_13' id='label_12_28_13' class='gform-field-label gform-field-label--type-inline'>Immune Disorders (such as allergies or lupus)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.14' type='checkbox'  value='Lung Disease'  id='choice_12_28_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_14' id='label_12_28_14' class='gform-field-label gform-field-label--type-inline'>Lung Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.15' type='checkbox'  value='Osteoporosis'  id='choice_12_28_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_15' id='label_12_28_15' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.16' type='checkbox'  value='Rheumatic Fever'  id='choice_12_28_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_16' id='label_12_28_16' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.17' type='checkbox'  value='Stroke'  id='choice_12_28_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_17' id='label_12_28_17' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.18' type='checkbox'  value='Surgical Operations'  id='choice_12_28_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_18' id='label_12_28_18' class='gform-field-label gform-field-label--type-inline'>Surgical Operations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.19' type='checkbox'  value='Valve Disease (Stenosis or Regurgitation)'  id='choice_12_28_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_19' id='label_12_28_19' class='gform-field-label gform-field-label--type-inline'>Valve Disease (Stenosis or Regurgitation)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_28_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.21' type='checkbox'  value='Varicose Veins'  id='choice_12_28_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_28_21' id='label_12_28_21' class='gform-field-label gform-field-label--type-inline'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_46\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_46'>Provide additional information about your abnormal heart rhythm<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_12_46' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_47\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_47'>Provide additional information about your asthma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_12_47' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_48\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_48'>Provide additional information about your artery disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_12_48' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_49\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_49'>Provide additional information about your chest discomfort<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_12_49' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_50\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_50'>Provide additional information about your diabetes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_12_50' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_51\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_51'>Provide additional information about your epilepsy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_12_51' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_52\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_52'>Provide additional information about your gout<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_52' id='input_12_52' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_53\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_53'>Provide additional information about your heart issues<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_12_53' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_54\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_54'>Provide additional information about your heart attack(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_12_54' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_55\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_55'>Provide additional information about your high blood pressure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_12_55' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_65\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_65'>Provide additional information about your hospitalization(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_65'>Please be sure to indicate why and when.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_12_65' class='textarea large'  aria-describedby=\"gfield_description_12_65\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_56\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_56'>Provide additional information about your immune disorder(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_12_56' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_57\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_57'>Provide additional information about your lung disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_12_57' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_58\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_58'>Provide additional information about your osteoporosis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_12_58' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_59\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_59'>Provide additional information about your rheumatic fever<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_12_59' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_60\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_60'>Provide additional information about your stroke<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_12_60' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_61\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_61'>Provide additional information about your operation(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_61'>Please include the kind of surgery and when.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_12_61' class='textarea large'  aria-describedby=\"gfield_description_12_61\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_62\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_62'>Provide additional information about your valve disease<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_12_62' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_68\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_68'>Provide additional information about your varicose veins<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_68' id='input_12_68' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Joint Injury<\/legend><div class='gfield_description' id='gfield_description_12_67'>Do you currently or have you ever had an injury (that required a visit to a physician) or surgery to any of the following joints? If so, check all that apply below.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_67'><div class='gchoice gchoice_12_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Ankle'  id='choice_12_67_1'   aria-describedby=\"gfield_description_12_67\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_1' id='label_12_67_1' class='gform-field-label gform-field-label--type-inline'>Ankle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.2' type='checkbox'  value='Back'  id='choice_12_67_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_2' id='label_12_67_2' class='gform-field-label gform-field-label--type-inline'>Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.3' type='checkbox'  value='Elbow'  id='choice_12_67_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_3' id='label_12_67_3' class='gform-field-label gform-field-label--type-inline'>Elbow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.4' type='checkbox'  value='Hand'  id='choice_12_67_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_4' id='label_12_67_4' class='gform-field-label gform-field-label--type-inline'>Hand<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.5' type='checkbox'  value='Hip'  id='choice_12_67_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_5' id='label_12_67_5' class='gform-field-label gform-field-label--type-inline'>Hip<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.6' type='checkbox'  value='Knee'  id='choice_12_67_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_6' id='label_12_67_6' class='gform-field-label gform-field-label--type-inline'>Knee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.7' type='checkbox'  value='Muscle Injuries or Tendonitis'  id='choice_12_67_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_7' id='label_12_67_7' class='gform-field-label gform-field-label--type-inline'>Muscle Injuries or Tendonitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.8' type='checkbox'  value='Neck'  id='choice_12_67_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_8' id='label_12_67_8' class='gform-field-label gform-field-label--type-inline'>Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.9' type='checkbox'  value='Shoulder'  id='choice_12_67_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_9' id='label_12_67_9' class='gform-field-label gform-field-label--type-inline'>Shoulder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_67_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.11' type='checkbox'  value='Wrist'  id='choice_12_67_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_67_11' id='label_12_67_11' class='gform-field-label gform-field-label--type-inline'>Wrist<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_63\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_63'>Provide additional information about your ankle injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_12_63' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_69\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_69'>Provide additional information about your back injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_12_69' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_70\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_70'>Provide additional information about your elbow injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_12_70' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_71\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_71'>Provide additional information about your hand injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_71' id='input_12_71' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_72\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_72'>Provide additional information about your hip injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_72' id='input_12_72' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_73\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_73'>Provide additional information about your knee injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_12_73' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_81\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_81'>Provide additional information about your muscle injury or tendonitis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_12_81' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_133\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_133'>Provide additional information about your neck injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_133' id='input_12_133' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_134\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_134'>Provide additional information about your shoulder injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_134' id='input_12_134' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_135\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_135'>Provide additional information about your wrist injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_135' id='input_12_135' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Limited Range of Motion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_75'>Do you have any condition or past injuries that limit the range of motion of your muscles or joints, spinal column or any other part of your body which may be aggravated by exercise?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_75'>\n\t\t\t<div class='gchoice gchoice_12_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_12_75_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_75\"   \/>\n\t\t\t\t\t<label for='choice_12_75_0' id='label_12_75_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_12_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_75_1' id='label_12_75_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_79\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_79'>Provide additional details about your limited range of motion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_12_79' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Broken Bones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_77'>Have you ever broken a bone?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_77'>\n\t\t\t<div class='gchoice gchoice_12_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Yes'  id='choice_12_77_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_77\"   \/>\n\t\t\t\t\t<label for='choice_12_77_0' id='label_12_77_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_12_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_77_1' id='label_12_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_95\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_95'>Provide additional details about your broken bone(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_12_95' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vehicle Accident, Fall, or Lifting Injuries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_78'>Were you ever injured as a result of a vehicle accident, a fall, or lifting an object (that required a visit to a physician)?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_78'>\n\t\t\t<div class='gchoice gchoice_12_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_12_78_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_78\"   \/>\n\t\t\t\t\t<label for='choice_12_78_0' id='label_12_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_12_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_78_1' id='label_12_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_94\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_94'>Provide additional details about your injuries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_94' id='input_12_94' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Head Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_98'>Have you ever suffered a head injury?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_98'>\n\t\t\t<div class='gchoice gchoice_12_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_12_98_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_98\"   \/>\n\t\t\t\t\t<label for='choice_12_98_0' id='label_12_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_12_98_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_98_1' id='label_12_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_97\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_97'>Provide additional details about your head injuries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_97' id='input_12_97' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_137\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Current Smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_137'>Do you currently smoke?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_137'>\n\t\t\t<div class='gchoice gchoice_12_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Yes'  id='choice_12_137_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_137\"   \/>\n\t\t\t\t\t<label for='choice_12_137_0' id='label_12_137_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='No'  id='choice_12_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_137_1' id='label_12_137_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Former Smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_96'>Did you previously smoke?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_96'>\n\t\t\t<div class='gchoice gchoice_12_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_12_96_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_96\"   \/>\n\t\t\t\t\t<label for='choice_12_96_0' id='label_12_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_12_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_96_1' id='label_12_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_136\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_136'>When did you quit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_136'>Please provide an estimate for when you quit smoking.<\/div><div class='ginput_container ginput_container_text'><input name='input_136' id='input_12_136' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_136\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_138\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_138'>Smoking Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_138'>For how many years did you smoke previously?<\/div><div class='ginput_container ginput_container_text'><input name='input_138' id='input_12_138' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_138\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_139\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_139'>How many?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_139'>How many cigarettes did you smoke per day?<\/div><div class='ginput_container ginput_container_text'><input name='input_139' id='input_12_139' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_139\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_105\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_105'>When did you start?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_105'>Please provide an estimate for when you started smoking.<\/div><div class='ginput_container ginput_container_text'><input name='input_105' id='input_12_105' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_105\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_103\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_103'>How many?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_103'>How many cigarettes do you smoke per day?<\/div><div class='ginput_container ginput_container_text'><input name='input_103' id='input_12_103' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_103\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_104\" class=\"gfield gfield--type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_104'>How often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_104'>How often do you smoke?<\/div><div class='ginput_container ginput_container_text'><input name='input_104' id='input_12_104' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_104\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Breathing Discomfort During Activity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_101'>Do you have any pain, discomfort, or shortness of breath with activity?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_101'>\n\t\t\t<div class='gchoice gchoice_12_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Yes'  id='choice_12_101_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_101\"   \/>\n\t\t\t\t\t<label for='choice_12_101_0' id='label_12_101_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='No'  id='choice_12_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_101_1' id='label_12_101_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_102\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_102'>Provide explain what you feel during activity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_12_102' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_109\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Caffeine<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_109'>Do you drink coffee and\/or other caffeinated beverages?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_109'>\n\t\t\t<div class='gchoice gchoice_12_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Yes'  id='choice_12_109_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_109\"   \/>\n\t\t\t\t\t<label for='choice_12_109_0' id='label_12_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='No'  id='choice_12_109_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_109_1' id='label_12_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_107\" class=\"gfield gfield--type-text gfield--width-half 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_12_107'>How much?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_12_107' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_106\" class=\"gfield gfield--type-text gfield--width-half 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_12_106'>How Often?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_12_106' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_12_110\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Alcohol<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_110'>Do you drink alcoholic beverages?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_110'>\n\t\t\t<div class='gchoice gchoice_12_110_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='Yes'  id='choice_12_110_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_110\"   \/>\n\t\t\t\t\t<label for='choice_12_110_0' id='label_12_110_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_110_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_110' type='radio' value='No'  id='choice_12_110_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_110_1' id='label_12_110_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_112\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_112'>How many drinks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_112'>How many drinks do you consume per week?<\/div><div class='ginput_container ginput_container_text'><input name='input_112' id='input_12_112' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_112\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_140\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_140'>Type of beverage?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_140'>Please specify your preferred type of alcoholic beverage (wine, beer, spirits).<\/div><div class='ginput_container ginput_container_text'><input name='input_140' id='input_12_140' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_140\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_100\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Family Health History<\/h3><\/div><fieldset id=\"field_12_76\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Family members ever had?<\/legend><div class='gfield_description' id='gfield_description_12_76'>Please check any of the following symptoms or health-related procedures that your blood-relatives (i.e. parents, siblings, grandparents) have experienced.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_76'><div class='gchoice gchoice_12_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Anemia'  id='choice_12_76_1'   aria-describedby=\"gfield_description_12_76\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_1' id='label_12_76_1' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Asthma'  id='choice_12_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_2' id='label_12_76_2' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='Cancer'  id='choice_12_76_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_3' id='label_12_76_3' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.4' type='checkbox'  value='Degenerative Bone or Joint Disease'  id='choice_12_76_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_4' id='label_12_76_4' class='gform-field-label gform-field-label--type-inline'>Degenerative Bone or Joint Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.5' type='checkbox'  value='Diabetes'  id='choice_12_76_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_5' id='label_12_76_5' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.6' type='checkbox'  value='Heart Attack'  id='choice_12_76_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_6' id='label_12_76_6' class='gform-field-label gform-field-label--type-inline'>Heart Attack<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.7' type='checkbox'  value='Heart Disease'  id='choice_12_76_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_7' id='label_12_76_7' class='gform-field-label gform-field-label--type-inline'>Heart Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.8' type='checkbox'  value='Heart Surgical Operations'  id='choice_12_76_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_8' id='label_12_76_8' class='gform-field-label gform-field-label--type-inline'>Heart Surgical Operations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.9' type='checkbox'  value='High Blood Pressure'  id='choice_12_76_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_9' id='label_12_76_9' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.11' type='checkbox'  value='High Cholesterol'  id='choice_12_76_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_11' id='label_12_76_11' class='gform-field-label gform-field-label--type-inline'>High Cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.12' type='checkbox'  value='Stroke'  id='choice_12_76_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_12' id='label_12_76_12' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.13' type='checkbox'  value='Sudden Death'  id='choice_12_76_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_13' id='label_12_76_13' class='gform-field-label gform-field-label--type-inline'>Sudden Death<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_76_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.14' type='checkbox'  value='Thyroid Disorder'  id='choice_12_76_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_76_14' id='label_12_76_14' class='gform-field-label gform-field-label--type-inline'>Thyroid Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_74\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_74'>Who in your family experienced anemia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_74'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_12_74' class='textarea large'  aria-describedby=\"gfield_description_12_74\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_82\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_82'>Who in your family experienced asthma?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_82'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_12_82' class='textarea large'  aria-describedby=\"gfield_description_12_82\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_83\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_83'>Who in your family experienced cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_83'>Please provide any context or details you can, including type of cancer.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_12_83' class='textarea large'  aria-describedby=\"gfield_description_12_83\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_85\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_85'>Who in your family experienced degenerative bone or joint disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_85'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_12_85' class='textarea large'  aria-describedby=\"gfield_description_12_85\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_84\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_84'>Who in your family experienced diabetes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_84'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_12_84' class='textarea large'  aria-describedby=\"gfield_description_12_84\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_86\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_86'>Who in your family experienced heart attack(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_86'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_12_86' class='textarea large'  aria-describedby=\"gfield_description_12_86\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_87\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_87'>Who in your family experienced heart disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_87'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_12_87' class='textarea large'  aria-describedby=\"gfield_description_12_87\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_89\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_89'>Who in your family experienced heart operation(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_89'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_12_89' class='textarea large'  aria-describedby=\"gfield_description_12_89\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_88\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_88'>Who in your family experienced high blood pressure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_88'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_12_88' class='textarea large'  aria-describedby=\"gfield_description_12_88\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_90\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_90'>Who in your family experienced high cholesterol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_90'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_12_90' class='textarea large'  aria-describedby=\"gfield_description_12_90\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_91\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_91'>Who in your family experienced stroke(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_91'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_12_91' class='textarea large'  aria-describedby=\"gfield_description_12_91\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_92\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_92'>Who in your family experienced sudden death?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_92'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_92' id='input_12_92' class='textarea large'  aria-describedby=\"gfield_description_12_92\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_93\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_93'>Who in your family experienced thyroid disorder(s)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_93'>Please provide any context or details you can.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_12_93' class='textarea large'  aria-describedby=\"gfield_description_12_93\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_125' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_12_125' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_3' class='gform_page' data-js='page-field-id-125' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_12_114\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Exercise History<\/h3><\/div><div id=\"field_12_115\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_115'>Hours Per Week Exercising<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_115'>Within the past three months.<\/div><div class='ginput_container ginput_container_select'><select name='input_115' id='input_12_115' class='large gfield_select'  aria-describedby=\"gfield_description_12_115\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Estimate your hours per week of physical activity<\/option><option value='Under an hour' >Under an hour<\/option><option value='1-2 hours' >1-2 hours<\/option><option value='3-5 hours' >3-5 hours<\/option><option value='6-10 hours' >6-10 hours<\/option><option value='10+ hours' >10+ hours<\/option><\/select><\/div><\/div><div id=\"field_12_116\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_116'>Days Per Week Exercising<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_116'>Within the past three months.<\/div><div class='ginput_container ginput_container_select'><select name='input_116' id='input_12_116' class='large gfield_select'  aria-describedby=\"gfield_description_12_116\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Approximate days per week of physical activity<\/option><option value='0' >0<\/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><\/select><\/div><\/div><fieldset id=\"field_12_118\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sport-Specific Exercise Per Week<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">days\/week<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">minutes\/day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">intensity<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><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_118_cell1 gform-grid-col' data-label='days\/week'><input aria-invalid='false'   aria-label='days\/week, Row 1' data-aria-label-template='days\/week, Row {0}' type='text' name='input_118[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_118_cell2 gform-grid-col' data-label='minutes\/day'><input aria-invalid='false'   aria-label='minutes\/day, Row 1' data-aria-label-template='minutes\/day, Row {0}' type='text' name='input_118[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_118_cell3 gform-grid-col' data-label='intensity'><input aria-invalid='false'   aria-label='intensity, Row 1' data-aria-label-template='intensity, Row {0}' type='text' name='input_118[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_119\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Weight Training Per Week<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">days\/week<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">minutes\/day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">intensity<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><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_119_cell1 gform-grid-col' data-label='days\/week'><input aria-invalid='false'   aria-label='days\/week, Row 1' data-aria-label-template='days\/week, Row {0}' type='text' name='input_119[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_119_cell2 gform-grid-col' data-label='minutes\/day'><input aria-invalid='false'   aria-label='minutes\/day, Row 1' data-aria-label-template='minutes\/day, Row {0}' type='text' name='input_119[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_119_cell3 gform-grid-col' data-label='intensity'><input aria-invalid='false'   aria-label='intensity, Row 1' data-aria-label-template='intensity, Row {0}' type='text' name='input_119[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_120\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Running Per Week<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">days\/week<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">minutes\/day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">intensity<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><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_120_cell1 gform-grid-col' data-label='days\/week'><input aria-invalid='false'   aria-label='days\/week, Row 1' data-aria-label-template='days\/week, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell2 gform-grid-col' data-label='minutes\/day'><input aria-invalid='false'   aria-label='minutes\/day, Row 1' data-aria-label-template='minutes\/day, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_120_cell3 gform-grid-col' data-label='intensity'><input aria-invalid='false'   aria-label='intensity, Row 1' data-aria-label-template='intensity, Row {0}' type='text' name='input_120[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_121\" class=\"gfield gfield--type-list gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cycling Per Week<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">days\/week<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">minutes\/day<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">intensity<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><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_121_cell1 gform-grid-col' data-label='days\/week'><input aria-invalid='false'   aria-label='days\/week, Row 1' data-aria-label-template='days\/week, Row {0}' type='text' name='input_121[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_121_cell2 gform-grid-col' data-label='minutes\/day'><input aria-invalid='false'   aria-label='minutes\/day, Row 1' data-aria-label-template='minutes\/day, Row {0}' type='text' name='input_121[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_121_cell3 gform-grid-col' data-label='intensity'><input aria-invalid='false'   aria-label='intensity, Row 1' data-aria-label-template='intensity, Row {0}' type='text' name='input_121[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_12_122\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_122'>Other Types of Exercise<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_122' id='input_12_122' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_12_124\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_124'>Current Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_124'>Provide in pounds (lbs).<\/div><div class='ginput_container ginput_container_number'><input name='input_124' id='input_12_124' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_124\" \/><\/div><\/div><div id=\"field_12_126\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_126'>Weight One Year Ago<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_126'>Provide in pounds (lbs).<\/div><div class='ginput_container ginput_container_number'><input name='input_126' id='input_12_126' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_126\" \/><\/div><\/div><div id=\"field_12_127\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_127'>Weight 5 Years Ago<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_127'>Provide in pounds (lbs).<\/div><div class='ginput_container ginput_container_number'><input name='input_127' id='input_12_127' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_127\" \/><\/div><\/div><div id=\"field_12_128\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_128'>Weight at Age 20<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_12_128'>Provide in pounds (lbs).<\/div><div class='ginput_container ginput_container_number'><input name='input_128' id='input_12_128' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_12_128\" \/><\/div><\/div><fieldset id=\"field_12_130\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Medical Exercise Advisory<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_12_130'>Has your physician ever advised you against exercise?<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_130'>\n\t\t\t<div class='gchoice gchoice_12_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Yes'  id='choice_12_130_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_130\"   \/>\n\t\t\t\t\t<label for='choice_12_130_0' id='label_12_130_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='No'  id='choice_12_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_130_1' id='label_12_130_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_131\" class=\"gfield gfield--type-textarea gfield--width-full 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_12_131'>Please explain when and why your physician advised against exercise?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_12_131' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_12_132\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Completion Confirmation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_12_132' tabindex='0'> I have answered the preceding questions to the best of my ability. I understood all of the questions asked of me and have been given the opportunity to have any of my concerns clarified to my satisfaction. I further understand that thorough and honest responses to these questions are essential to my safety and prudent recommendations from the health care professionals.<\/div><div class='ginput_container ginput_container_consent'><input name='input_132.1' id='input_12_132_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_12_132\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_132_1' >I agree<\/label><input type='hidden' name='input_132.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_132.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_12_141\" class=\"gfield gfield--type-captcha field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_141'>CAPTCHA<\/label><div id='input_12_141' class='ginput_container ginput_recaptcha' data-sitekey='6LexzgYUAAAAAG6hKKKgKWpKgPS5REIB3KMCQ1WA'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_12_142\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_142'>Comments<\/label><div class='gfield_description' id='gfield_description_12_142'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_142' id='input_12_142' type='text' value='' autocomplete='new-password'\/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_12' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_12' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_12' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_12' id='gform_theme_12' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_12' id='gform_style_settings_12' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_12' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='12' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_12' 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