{"id":1721,"date":"2018-08-06T09:32:58","date_gmt":"2018-08-06T09:32:58","guid":{"rendered":"https:\/\/drsusanjanssens.com\/?page_id=1721"},"modified":"2018-08-06T09:32:58","modified_gmt":"2018-08-06T09:32:58","slug":"general-health-questionnaire","status":"publish","type":"page","link":"https:\/\/drsusanjanssens.com\/general-health-questionnaire\/","title":{"rendered":"General Health Questionnaire"},"content":{"rendered":"\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/1721'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>General Health Questionnaire<\/h3>\n                            <span class='gform_description'>Comprehensive Patient Questionnaire<\/span>\n                        <\/div>\n                        <div class='gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id='field_1_18'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_18_3' >Name<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_1_18'>\n                            \n                            <span id='input_1_18_3_container' class='name_first' >\n                                                    <input type='text' name='input_18.3' id='input_1_18_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_18_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_18_6_container' class='name_last' >\n                                                    <input type='text' name='input_18.6' id='input_1_18_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_18_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_1_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_2' >Date of Birth<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_1_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_3' >Age<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_14'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_14' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_1_14' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_15'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_15' >Place of Employment<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_5_1' >Home Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gfield_trigger_change' id='input_1_5' >\n                         <span class='ginput_full address_line_1' id='input_1_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_1_5_1' value=''   \/>\n                                        <label for='input_1_5_1' id='input_1_5_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_1_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_1_5_2' value=''   \/>\n                                        <label for='input_1_5_2' id='input_1_5_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_1_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_1_5_3' value=''   \/>\n                                    <label for='input_1_5_3' id='input_1_5_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_1_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_1_5_4' value=''     \/>\n                                        <label for='input_1_5_4' id='input_1_5_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_1_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_1_5_5' value=''   \/>\n                                    <label for='input_1_5_5' id='input_1_5_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_1_5_6_container' >\n                                        <select name='input_5.6' id='input_1_5_6'  ><option value='' selected='selected'><\/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='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/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='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/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='Czech Republic' >Czech Republic<\/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='East Timor' >East Timor<\/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='Ethiopia' >Ethiopia<\/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 Polynesia' >French Polynesia<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macedonia' >Macedonia<\/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='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/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='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 Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/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='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='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Saint Martin' >Saint Martin<\/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='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/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' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                        <label for='input_1_5_6' id='input_1_5_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_1_6'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_6' >Contact Number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_17'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_17_3' >Emergency Contact Number<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gfield_trigger_change' id='input_1_17'>\n                            \n                            <span id='input_1_17_3_container' class='name_first' >\n                                                    <input type='text' name='input_17.3' id='input_1_17_3' value='' aria-label='First name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_17_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_17_6_container' class='name_last' >\n                                                    <input type='text' name='input_17.6' id='input_1_17_6' value='' aria-label='Last name'    aria-invalid=\"false\" \/>\n                                                    <label for='input_1_17_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_1_16'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_16' >Emergency Contact Number<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_1_16' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_7'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_7' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_1_7' type='text' value='' class='medium'      aria-invalid=\"false\"\/>\n                        <\/div><\/li><li id='field_1_8'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Marital Status<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_8'><li class='gchoice_1_8_0'><input name='input_8' type='radio' value='Single'  id='choice_1_8_0'     \/><label for='choice_1_8_0' id='label_1_8_0'>Single<\/label><\/li><li class='gchoice_1_8_1'><input name='input_8' type='radio' value='Married'  id='choice_1_8_1'     \/><label for='choice_1_8_1' id='label_1_8_1'>Married<\/label><\/li><li class='gchoice_1_8_2'><input name='input_8' type='radio' value='Divorced'  id='choice_1_8_2'     \/><label for='choice_1_8_2' id='label_1_8_2'>Divorced<\/label><\/li><li class='gchoice_1_8_3'><input name='input_8' type='radio' value='Widowed'  id='choice_1_8_3'     \/><label for='choice_1_8_3' id='label_1_8_3'>Widowed<\/label><\/li><li class='gchoice_1_8_4'><input name='input_8' type='radio' value='Common Law'  id='choice_1_8_4'     \/><label for='choice_1_8_4' id='label_1_8_4'>Common Law<\/label><\/li><\/ul><\/div><\/li><li id='field_1_9'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_9' >First  &amp; Last Name of Partner<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_102'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Children<\/h2><\/li><li id='field_1_10'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Children<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_10'><li class='gchoice_1_10_0'><input name='input_10' type='radio' value='Yes'  id='choice_1_10_0'     \/><label for='choice_1_10_0' id='label_1_10_0'>Yes<\/label><\/li><li class='gchoice_1_10_1'><input name='input_10' type='radio' value='No'  id='choice_1_10_1'     \/><label for='choice_1_10_1' id='label_1_10_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_103'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_103_shim' >If Yes\/Details<\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img.add_list_item,\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img.delete_list_item {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img.add_list_item:hover,\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img.delete_list_item:hover {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_103_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_103 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_103_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_103_col_2' class='gfield_list_col_even' \/><col id='gfield_list_103_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Age<\/th><th>Sex<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_103_cell1' data-label='Age'><input type='text' name='input_103[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_103_cell2' data-label='Sex'><select title='Sex'name='input_103[]'   ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Referral<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_19'><li class='gchoice_1_19_0'><input name='input_19' type='radio' value='Self'  id='choice_1_19_0'     \/><label for='choice_1_19_0' id='label_1_19_0'>Self<\/label><\/li><li class='gchoice_1_19_1'><input name='input_19' type='radio' value='Physician'  id='choice_1_19_1'     \/><label for='choice_1_19_1' id='label_1_19_1'>Physician<\/label><\/li><li class='gchoice_1_19_2'><input name='input_19' type='radio' value='Other'  id='choice_1_19_2'     \/><label for='choice_1_19_2' id='label_1_19_2'>Other<\/label><\/li><\/ul><\/div><\/li><li id='field_1_104'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_104_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_104_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_104 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_104_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_104_col_2' class='gfield_list_col_even' \/><col id='gfield_list_104_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_104_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Physician<\/th><th>First &amp; Last Name<\/th><th>Contact Number<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_104_cell1' data-label='Physician'><select title='Physician'name='input_104[]'   ><option value='Physician' >Physician<\/option><option value='Dentist' >Dentist<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_104_cell2' data-label='First &amp; Last Name'><input type='text' name='input_104[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_104_cell3' data-label='Contact Number'><input type='text' name='input_104[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_24'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_24' >AHC #<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_100'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Current Health Professionals<\/h2><div class='gsection_description'>List of Health Professionals you currently see <\/div><\/li><li id='field_1_101'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_101_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_101_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_101 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_101_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_101_col_2' class='gfield_list_col_even' \/><col id='gfield_list_101_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_101_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>First &amp; Last Name<\/th><th>Practice<\/th><th>Contact Number<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_101_cell1' data-label='First &amp; Last Name'><input type='text' name='input_101[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_101_cell2' data-label='Practice'><input type='text' name='input_101[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_101_cell3' data-label='Contact Number'><input type='text' name='input_101[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_97'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Current health conditions you desire improvement in and length of time they have been a concern to you, placed in order of importance<\/h2><\/li><li id='field_1_98'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_98_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_98_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_98 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_98_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_98_col_2' class='gfield_list_col_even' \/><col id='gfield_list_98_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Health Problem<\/th><th>Length of Time<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_98_cell1' data-label='Health Problem'><input type='text' name='input_98[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_98_cell2' data-label='Length of Time'><input type='text' name='input_98[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_47'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_47' >To what extent do these areas interfere with your daily activities (work, sleep, etc.)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_1_47' class='textarea medium'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_48'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_48' >Have you been given a diagnosis for this problem and, if so, what?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_1_48' class='textarea medium'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_89'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Family History<\/h2><div class='gsection_description'>Check the box if there is a family history for the following health problems. If the health condition resulted in a\nfamily member death, please mark the third column with DC.<\/div><\/li><li id='field_1_60'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_60_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_60_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_60 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_60_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_60_col_2' class='gfield_list_col_even' \/><col id='gfield_list_60_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_60_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>Health Issue<\/th><th>Family History<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_60_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_60[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_60_cell2' data-label='Health Issue'><select title='Health Issue'name='input_60[]'   ><option value='Allergies\/Hay Fever' >Allergies\/Hay Fever<\/option><option value='Alcoholism' >Alcoholism<\/option><option value='Anemia' >Anemia<\/option><option value='Arthritis' >Arthritis<\/option><option value='Asthma' >Asthma<\/option><option value='Cancer' >Cancer<\/option><option value='Diabetes' >Diabetes<\/option><option value='Digestive Illness' >Digestive Illness<\/option><option value='Epilepsy' >Epilepsy<\/option><option value='Glaucoma' >Glaucoma<\/option><option value='Headaches' >Headaches<\/option><option value='Heart Disease' >Heart Disease<\/option><option value='High Cholesterol' >High Cholesterol<\/option><option value='High Blood Pressure' >High Blood Pressure<\/option><option value='Kidney Disease' >Kidney Disease<\/option><option value='Mental Illness' >Mental Illness<\/option><option value='Obesity' >Obesity<\/option><option value='Stroke' >Stroke<\/option><option value='Syphilis' >Syphilis<\/option><option value=' Thyroid Condition' > Thyroid Condition<\/option><option value='Tuberculosis' >Tuberculosis<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_60_cell3' data-label='Family History'><select title='Family History'name='input_60[]'   ><option value='None' >None<\/option><option value='MGM: maternal grandmother' >MGM: maternal grandmother<\/option><option value='PGM: paternal grandmother' >PGM: paternal grandmother<\/option><option value='MGF: maternal grandfather' >MGF: maternal grandfather<\/option><option value='PGF: paternal grandfather' >PGF: paternal grandfather<\/option><option value='F: father' >F: father<\/option><option value='M: mother' >M: mother<\/option><option value='B: brother' >B: brother<\/option><option value='S: sister' >S: sister<\/option><option value='Sp: spouse' >Sp: spouse<\/option><option value='C: children' >C: children<\/option><option value='DC: deceased' >DC: deceased<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 22)' onkeypress='gformAddListItem(this, 22)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 22)' onkeypress='gformDeleteListItem(this, 22)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_96'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Past Medical History<\/h2><\/li><li id='field_1_105'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_105_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_105_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_105 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_105_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_105_col_2' class='gfield_list_col_even' \/><col id='gfield_list_105_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_105_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Hospitalisation<\/th><th>Year<\/th><th>Reason<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_105_cell1' data-label='Hospitalisation'><select title='Hospitalisation'name='input_105[]'   ><option value='Hospitalisation' >Hospitalisation<\/option><option value='Surgeries' >Surgeries<\/option><option value='Serious Illnesses\/Injuries\/Accidents' >Serious Illnesses\/Injuries\/Accidents<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_105_cell2' data-label='Year'><input type='text' name='input_105[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_105_cell3' data-label='Reason'><input type='text' name='input_105[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_88'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Childhood Illnesses<\/h2><div class='gsection_description'>Health as a Child (1:poor to 10:excellent).  If less than 8 please explain.<\/div><\/li><li id='field_1_77'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_77_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_77_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_77 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_77_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_77_col_2' class='gfield_list_col_even' \/><col id='gfield_list_77_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_77_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Rating<\/th><th>Illness<\/th><th>Explanation if less than 8<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_77_cell1' data-label='Rating'><select title='Rating'name='input_77[]'   ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_77_cell2' data-label='Illness'><select title='Illness'name='input_77[]'   ><option value=' Rheumatic Fever' > Rheumatic Fever<\/option><option value='German Measles' >German Measles<\/option><option value='Polio' >Polio<\/option><option value='Allergies' >Allergies<\/option><option value='Chicken Pox' >Chicken Pox<\/option><option value='Frequent Colds\/Flu' >Frequent Colds\/Flu<\/option><option value='Mumps' >Mumps<\/option><option value='Ear Infection' >Ear Infection<\/option><option value=' Skin Conditions (Eczema,Psoriasis)' > Skin Conditions (Eczema,Psoriasis)<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_77_cell3' data-label='Explanation if less than 8'><input type='text' name='input_77[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 10)' onkeypress='gformAddListItem(this, 10)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 10)' onkeypress='gformDeleteListItem(this, 10)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_82'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_82' >Other<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_1_82' class='textarea medium'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_83'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_1_83' >Vaccinations<\/label><div class='gfield_description'>Type\/Year\/Adverse Reactions<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_1_83' class='textarea medium'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_87'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Allergies<\/h2><div class='gsection_description'>List all known<\/div><\/li><li id='field_1_84'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_84_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_84_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_84 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_84_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_84_col_2' class='gfield_list_col_even' \/><col id='gfield_list_84_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_84_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Allergy<\/th><th>Items<\/th><th>Reaction<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_84_cell1' data-label='Allergy'><select title='Allergy'name='input_84[]'   ><option value='Drugs' >Drugs<\/option><option value='Foods' >Foods<\/option><option value='Others' >Others<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_84_cell2' data-label='Items'><input type='text' name='input_84[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_84_cell3' data-label='Reaction'><input type='text' name='input_84[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_90'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Pets<\/h2><\/li><li id='field_1_91'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_91_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_91_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_91 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_91_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_91_col_2' class='gfield_list_col_even' \/><col id='gfield_list_91_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Kind<\/th><th>How Many<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_91_cell1' data-label='Kind'><input type='text' name='input_91[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_91_cell2' data-label='How Many'><select title='How Many'name='input_91[]'   ><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='More' >More<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_94'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Medication<\/h2><div class='gsection_description'>Prescription & Over-the-Counter<\/div><\/li><li id='field_1_95'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_95_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_95_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_95 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_95_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_95_col_2' class='gfield_list_col_even' \/><col id='gfield_list_95_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_95_col_4' class='gfield_list_col_even' \/><col id='gfield_list_95_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Medication<\/th><th>Dose<\/th><th>How Long<\/th><th>For What<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_95_cell1' data-label='Medication'><input type='text' name='input_95[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_95_cell2' data-label='Dose'><input type='text' name='input_95[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_95_cell3' data-label='How Long'><input type='text' name='input_95[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_95_cell4' data-label='For What'><input type='text' name='input_95[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_106'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Supplements<\/h2><div class='gsection_description'>Non-Prescription\/Herbal\/Nutritional\/Any over-the-counter items<\/div><\/li><li id='field_1_107'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_107_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_107_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_107 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_107_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_107_col_2' class='gfield_list_col_even' \/><col id='gfield_list_107_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_107_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Supplement<\/th><th>Dosage<\/th><th>How Long on Supplement<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_107_cell1' data-label='Supplement'><input type='text' name='input_107[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_107_cell2' data-label='Dosage'><input type='text' name='input_107[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_107_cell3' data-label='How Long on Supplement'><input type='text' name='input_107[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_108'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>General Anesthetic<\/h2><div class='gsection_description'>Have you ever had general anesthetic?<\/div><\/li><li id='field_1_110'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_110_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_110_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_110 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_110_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_110_col_2' class='gfield_list_col_even' \/><col id='gfield_list_110_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th><\/th><th>If yes, how long?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_110_cell1' data-label=''><select title=''name='input_110[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_110_cell2' data-label='If yes, how long?'><input type='text' name='input_110[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_111'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Antibiotics<\/h2><div class='gsection_description'>Have you been on antibiotics?<\/div><\/li><li id='field_1_112'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_112_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_112_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_112 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_112_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_112_col_2' class='gfield_list_col_even' \/><col id='gfield_list_112_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Yes\/No<\/th><th>If yes, when and how long?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_112_cell1' data-label='Yes\/No'><select title='Yes\/No'name='input_112[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_112_cell2' data-label='If yes, when and how long?'><input type='text' name='input_112[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_113'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Dental<\/h2><div class='gsection_description'>To the best of your knowledge please list all dental work\/treatments you have undergone.  Include fillings (specify type), pulled teeth, root canals, bridges, crowns, dentures, braces, retainer\/splints, accidents\/injuries or any other type of dental\/jaw surgery<\/div><\/li><li id='field_1_114'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_114_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_114_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_114 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_114_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_114_col_2' class='gfield_list_col_even' \/><col id='gfield_list_114_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_114_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Date<\/th><th>Dentist Name<\/th><th>Treatment<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_114_cell1' data-label='Date'><input type='text' name='input_114[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_114_cell2' data-label='Dentist Name'><input type='text' name='input_114[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_114_cell3' data-label='Treatment'><input type='text' name='input_114[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_115'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_115' >Describe any current dental concerns or symptoms<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_1_115' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_117'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_117_shim' >Are you aware of any grinding of your teeth or clenching your jaw?<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_117_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_117 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_117_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_117_col_2' class='gfield_list_col_even' \/><col id='gfield_list_117_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>No<\/th><th>If yes, when?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_117_cell1' data-label='No'><select title='No'name='input_117[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_117_cell2' data-label='If yes, when?'><select title='If yes, when?'name='input_117[]'   ><option value='Day' >Day<\/option><option value='Night' >Night<\/option><option value='Both' >Both<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_118'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Chemicals<\/h2><div class='gsection_description'>Please list any current or past exposures to solvents, chemicals, cleaning agents, insecticides, herbicides, pesticides, chemical\/metal vapors and\/or dry cleaning agents<\/div><\/li><li id='field_1_119'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_119_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_119_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_119 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_119_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_119_col_2' class='gfield_list_col_even' \/><col id='gfield_list_119_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_119_col_4' class='gfield_list_col_even' \/><col id='gfield_list_119_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Item<\/th><th>When<\/th><th>How Long<\/th><th>Where<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_119_cell1' data-label='Item'><input type='text' name='input_119[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_119_cell2' data-label='When'><input type='text' name='input_119[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_119_cell3' data-label='How Long'><input type='text' name='input_119[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_119_cell4' data-label='Where'><select title='Where'name='input_119[]'   ><option value='Home' >Home<\/option><option value='Work' >Work<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_120'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Travel<\/h2><div class='gsection_description'>List back country & third world trips<\/div><\/li><li id='field_1_121'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_121_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_121_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_121 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_121_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_121_col_2' class='gfield_list_col_even' \/><col id='gfield_list_121_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_121_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Country<\/th><th>Travel Dates<\/th><th>Illness or Trauma<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_121_cell1' data-label='Country'><input type='text' name='input_121[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_121_cell2' data-label='Travel Dates'><input type='text' name='input_121[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_121_cell3' data-label='Illness or Trauma'><input type='text' name='input_121[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_122'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Lifestyle<\/h2><\/li><li id='field_1_123'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_123_shim' >Do You Enjoy Your Work<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_123_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_123 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_123_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_123_col_2' class='gfield_list_col_even' \/><col id='gfield_list_123_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Yes<\/th><th>If no, why?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_123_cell1' data-label='Yes'><select title='Yes'name='input_123[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_123_cell2' data-label='If no, why?'><input type='text' name='input_123[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_124'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_124' >Previous Occupations<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_1_124' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_125'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_125_shim' >Please indicate on the line below where you feel your current balance between work and play is<\/label><div class='gfield_description'>0: All Work - 10: All Play<\/div><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_125_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_125 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_125_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_125_col_2' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>0<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_125_cell1' data-label='0'><select title='0'name='input_125[]'   ><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><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_126'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Physical Fitness<\/h2><\/li><li id='field_1_127'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do You Exercise Regularly?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_127'><li class='gchoice_1_127_0'><input name='input_127' type='radio' value='Yes'  id='choice_1_127_0'     \/><label for='choice_1_127_0' id='label_1_127_0'>Yes<\/label><\/li><li class='gchoice_1_127_1'><input name='input_127' type='radio' value='No'  id='choice_1_127_1'     \/><label for='choice_1_127_1' id='label_1_127_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_128'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_128' >Describe Your Program<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_1_128' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_130'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Hobbies<\/h2><div class='gsection_description'>Please list your hobbies or recreational interests<\/div><\/li><li id='field_1_131'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_131' ><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_131' id='input_1_131' class='textarea medium'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_1_132'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Support\/Stressors &amp; Personal Growth<\/h2><\/li><li id='field_1_133'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you get along with your family?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_133'><li class='gchoice_1_133_0'><input name='input_133' type='radio' value='Yes'  id='choice_1_133_0'     \/><label for='choice_1_133_0' id='label_1_133_0'>Yes<\/label><\/li><li class='gchoice_1_133_1'><input name='input_133' type='radio' value='No'  id='choice_1_133_1'     \/><label for='choice_1_133_1' id='label_1_133_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_1_134'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_134_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_134_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_134 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_134_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_134_col_2' class='gfield_list_col_even' \/><col id='gfield_list_134_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Please list the stress factors that affect you the most<\/th><th>Please list the people\/areas that support you the most<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_134_cell1' data-label='Please list the stress factors that affect you the most'><input type='text' name='input_134[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_134_cell2' data-label='Please list the people\/areas that support you the most'><input type='text' name='input_134[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_135'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_135' >Do you currently follow a religious\/spiritual belief system?<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_1_135' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_136'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_136' >Do you feel supported and comfortable with this belief system?<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_1_136' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_137'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_137_shim' >Do You...<\/label><div class='gfield_description'>Select one or more by adding a row (+)<\/div><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_137_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_137 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_137_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_137_col_2' class='gfield_list_col_even' \/><col id='gfield_list_137_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Meditate<\/th><th>How Often\/Describe<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_137_cell1' data-label='Meditate'><select title='Meditate'name='input_137[]'   ><option value='Meditate' >Meditate<\/option><option value='Pray' >Pray<\/option><option value=' Use Visualization ' > Use Visualization <\/option><option value='Use Relaxation Techniques' >Use Relaxation Techniques<\/option><option value='Use other Techniques.  Describe?' >Use other Techniques.  Describe?<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_137_cell2' data-label='How Often\/Describe'><input type='text' name='input_137[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_138'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >How might you finish this statement in regards to suggestions\/programs for your health : I ...<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_138'><li class='gchoice_1_138_0'><input name='input_138' type='radio' value='can follow the plans\/programs'  id='choice_1_138_0'     \/><label for='choice_1_138_0' id='label_1_138_0'>can follow the plans\/programs<\/label><\/li><li class='gchoice_1_138_1'><input name='input_138' type='radio' value='start programs, then let things slide'  id='choice_1_138_1'     \/><label for='choice_1_138_1' id='label_1_138_1'>start programs, then let things slide<\/label><\/li><li class='gchoice_1_138_2'><input name='input_138' type='radio' value='prefer choosing from options'  id='choice_1_138_2'     \/><label for='choice_1_138_2' id='label_1_138_2'>prefer choosing from options<\/label><\/li><li class='gchoice_1_138_3'><input name='input_138' type='radio' value='am easily overwhelmed'  id='choice_1_138_3'     \/><label for='choice_1_138_3' id='label_1_138_3'>am easily overwhelmed<\/label><\/li><\/ul><\/div><\/li><li id='field_1_139'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_139' >How will you know when you are feeling better<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_1_139' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_140'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_140' >How might things look for you when your life is very good?<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_1_140' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_141'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_141' >Do you have any concerns or reservations in pursuing complementary &amp; alternative therapies?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_1_141' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_142'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Smoking<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_143'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_143_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_143_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_143 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_143_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_143_col_2' class='gfield_list_col_even' \/><col id='gfield_list_143_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_143_col_4' class='gfield_list_col_even' \/><col id='gfield_list_143_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Product<\/th><th>How Often<\/th><th>How long have you been smoking?<\/th><th>Quit. When?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_143_cell1' data-label='Product'><select title='Product'name='input_143[]'   ><option value='Cigarettes' >Cigarettes<\/option><option value='Cigars' >Cigars<\/option><option value='Pipe Tobacco' >Pipe Tobacco<\/option><option value='Marijuana' >Marijuana<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_143_cell2' data-label='How Often'><input type='text' name='input_143[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_143_cell3' data-label='How long have you been smoking?'><input type='text' name='input_143[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_143_cell4' data-label='Quit. When?'><input type='text' name='input_143[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_144'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Drinking<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_145'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_145_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_145_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_145 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_145_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_145_col_2' class='gfield_list_col_even' \/><col id='gfield_list_145_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_145_col_4' class='gfield_list_col_even' \/><col id='gfield_list_145_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Product<\/th><th>How Often<\/th><th>How long have you been drinking?<\/th><th>Quit. When?<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_145_cell1' data-label='Product'><select title='Product'name='input_145[]'   ><option value='Liquor' >Liquor<\/option><option value='Beer' >Beer<\/option><option value='Wine' >Wine<\/option><option value='Coffee' >Coffee<\/option><option value='Soft Drinks' >Soft Drinks<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_145_cell2' data-label='How Often'><input type='text' name='input_145[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_145_cell3' data-label='How long have you been drinking?'><input type='text' name='input_145[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_145_cell4' data-label='Quit. When?'><input type='text' name='input_145[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_146'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Diet<\/h2><div class='gsection_description'>For each \u2018yes\u2019 list type, serving size & frequency<\/div><\/li><li id='field_1_148'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >If Vegetarian, what kind?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_148'><li class='gchoice_1_148_0'><input name='input_148' type='radio' value='Lacto'  id='choice_1_148_0'     \/><label for='choice_1_148_0' id='label_1_148_0'>Lacto<\/label><\/li><li class='gchoice_1_148_1'><input name='input_148' type='radio' value='Ovo'  id='choice_1_148_1'     \/><label for='choice_1_148_1' id='label_1_148_1'>Ovo<\/label><\/li><li class='gchoice_1_148_2'><input name='input_148' type='radio' value='Lacto-Ovo'  id='choice_1_148_2'     \/><label for='choice_1_148_2' id='label_1_148_2'>Lacto-Ovo<\/label><\/li><li class='gchoice_1_148_3'><input name='input_148' type='radio' value='Pesco'  id='choice_1_148_3'     \/><label for='choice_1_148_3' id='label_1_148_3'>Pesco<\/label><\/li><li class='gchoice_1_148_4'><input name='input_148' type='radio' value='Vegan'  id='choice_1_148_4'     \/><label for='choice_1_148_4' id='label_1_148_4'>Vegan<\/label><\/li><li class='gchoice_1_148_5'><input name='input_148' type='radio' value='Other'  id='choice_1_148_5'     \/><label for='choice_1_148_5' id='label_1_148_5'>Other<\/label><\/li><\/ul><\/div><\/li><li id='field_1_147'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_147_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_147_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_147 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_147_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_147_col_2' class='gfield_list_col_even' \/><col id='gfield_list_147_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_147_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Type<\/th><th>Yes\/No<\/th><th>Serving size\/Frequency<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_147_cell1' data-label='Type'><select title='Type'name='input_147[]'   ><option value='Vegetarian' >Vegetarian<\/option><option value='Meat' >Meat<\/option><option value='Fish' >Fish<\/option><option value='Fowl' >Fowl<\/option><option value='Dairy' >Dairy<\/option><option value='Eggs' >Eggs<\/option><option value='Beans\/Legumes' >Beans\/Legumes<\/option><option value='Fruit' >Fruit<\/option><option value='Vegetables' >Vegetables<\/option><option value='Grains\/Bread\/Pasta\/Cereal' >Grains\/Bread\/Pasta\/Cereal<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_147_cell2' data-label='Yes\/No'><select title='Yes\/No'name='input_147[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_147_cell3' data-label='Serving size\/Frequency'><input type='text' name='input_147[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 11)' onkeypress='gformAddListItem(this, 11)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 11)' onkeypress='gformDeleteListItem(this, 11)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_150'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_150_shim' >Meals<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_150_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_150 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_150_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_150_col_2' class='gfield_list_col_even' \/><col id='gfield_list_150_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_150_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Breakfast<\/th><th>Time<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_150_cell1' data-label='Breakfast'><input type='text' name='input_150[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_150_cell2' data-label='Time'><input type='text' name='input_150[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_150_cell3' data-label='Food\/Drink'><input type='text' name='input_150[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_151'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_151_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_151_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_151 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_151_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_151_col_2' class='gfield_list_col_even' \/><col id='gfield_list_151_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_151_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Lunch<\/th><th>Time<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_151_cell1' data-label='Lunch'><input type='text' name='input_151[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_151_cell2' data-label='Time'><input type='text' name='input_151[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_151_cell3' data-label='Food\/Drink'><input type='text' name='input_151[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_152'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_152_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_152_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_152 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_152_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_152_col_2' class='gfield_list_col_even' \/><col id='gfield_list_152_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_152_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Dinner<\/th><th>Time<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_152_cell1' data-label='Dinner'><input type='text' name='input_152[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_152_cell2' data-label='Time'><input type='text' name='input_152[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_152_cell3' data-label='Food\/Drink'><input type='text' name='input_152[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_153'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_153_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_153_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_153 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_153_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_153_col_2' class='gfield_list_col_even' \/><col id='gfield_list_153_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_153_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Snacks\/Desert<\/th><th>Time<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_153_cell1' data-label='Snacks\/Desert'><input type='text' name='input_153[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_153_cell2' data-label='Time'><input type='text' name='input_153[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_153_cell3' data-label='Food\/Drink'><input type='text' name='input_153[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_154'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_154_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_154_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_154 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_154_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_154_col_2' class='gfield_list_col_even' \/><col id='gfield_list_154_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_154_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Drinks<\/th><th>N\/A<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_154_cell1' data-label='Drinks'><input type='text' name='input_154[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_154_cell2' data-label='N\/A'><input type='text' name='input_154[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_154_cell3' data-label='Food\/Drink'><input type='text' name='input_154[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_155'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_155_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_155_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_155 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_155_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_155_col_2' class='gfield_list_col_even' \/><col id='gfield_list_155_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_155_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Cravings<\/th><th>N\/A<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_155_cell1' data-label='Cravings'><input type='text' name='input_155[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_155_cell2' data-label='N\/A'><input type='text' name='input_155[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_155_cell3' data-label='Food\/Drink'><input type='text' name='input_155[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_156'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_156_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_156_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_156 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_156_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_156_col_2' class='gfield_list_col_even' \/><col id='gfield_list_156_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_156_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Aversions<\/th><th>N\/A<\/th><th>Food\/Drink<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_156_cell1' data-label='Aversions'><input type='text' name='input_156[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_156_cell2' data-label='N\/A'><input type='text' name='input_156[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_156_cell3' data-label='Food\/Drink'><input type='text' name='input_156[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_157'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_157' >What kind of water do you drink, and how much?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_1_157' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_158'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_158' >Please mention any foods or drinks that aggravate your symptoms or that you find hard to digest<\/label><div class='ginput_container ginput_container_text'><input name='input_158' id='input_1_158' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_159'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_159' >How long have you been following this diet?<\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_1_159' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_161'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_1_161' >Do you eat or use any of the following?<\/label><div class='gfield_description'>More than one choice enabled<\/div><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_161[]' id='input_1_161'  class='medium gfield_select'  ><option value='Margerine' >Margerine<\/option><option value='Processed\/Deli Meats' >Processed\/Deli Meats<\/option><option value='Alumninum Pots\/Utensils' >Alumninum Pots\/Utensils<\/option><option value='Lard' >Lard<\/option><option value='Sugar' >Sugar<\/option><option value='Microwave' >Microwave<\/option><option value='Crystal\/Packaged Drinks' >Crystal\/Packaged Drinks<\/option><option value='Candy' >Candy<\/option><option value='Shortening' >Shortening<\/option><option value='Artificial Sweeteners' >Artificial Sweeteners<\/option><option value='Fried Foods' >Fried Foods<\/option><\/select><\/div><\/li><li id='field_1_162'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Symptom Review<\/h2><div class='gsection_description'>Please complete the following section as thoroughly as you can. For every question that you answer \u201cyes\u201d or \u201c past\u201d,\nplease explain your answer further on the accompanying line.<\/div><\/li><li id='field_1_164'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_164_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_164_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_164 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_164_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_164_col_2' class='gfield_list_col_even' \/><col id='gfield_list_164_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_164_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Weight<\/th><th>Kg or Pounds<\/th><th>Reason<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_164_cell1' data-label='Weight'><input type='text' name='input_164[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_164_cell2' data-label='Kg or Pounds'><input type='text' name='input_164[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_164_cell3' data-label='Reason'><input type='text' name='input_164[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_166'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_166_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_166_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_166 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_166_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_166_col_2' class='gfield_list_col_even' \/><col id='gfield_list_166_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_166_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Weight 1 Year Ago<\/th><th>Kg or Pounds<\/th><th>Reason<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_166_cell1' data-label='Weight 1 Year Ago'><input type='text' name='input_166[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_166_cell2' data-label='Kg or Pounds'><input type='text' name='input_166[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_166_cell3' data-label='Reason'><input type='text' name='input_166[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_167'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_167_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_167_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_167 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_167_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_167_col_2' class='gfield_list_col_even' \/><col id='gfield_list_167_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_167_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Maximum Weight<\/th><th>Kg or Pounds<\/th><th>Reason<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_167_cell1' data-label='Maximum Weight'><input type='text' name='input_167[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_167_cell2' data-label='Kg or Pounds'><input type='text' name='input_167[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_167_cell3' data-label='Reason'><input type='text' name='input_167[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_168'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_168_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_168_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_168 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_168_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_168_col_2' class='gfield_list_col_even' \/><col id='gfield_list_168_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_168_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>When<\/th><th>Kg or Pounds<\/th><th>Reason<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_168_cell1' data-label='When'><input type='text' name='input_168[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_168_cell2' data-label='Kg or Pounds'><input type='text' name='input_168[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_168_cell3' data-label='Reason'><input type='text' name='input_168[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_169'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_169_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_169_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_169 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_169_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_169_col_2' class='gfield_list_col_even' \/><col id='gfield_list_169_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Height<\/th><th>cm<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_169_cell1' data-label='Height'><input type='text' name='input_169[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_169_cell2' data-label='cm'><input type='text' name='input_169[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_170'  class='gfield gw-number-rows field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_170_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_170_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_170 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_170_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_170_col_2' class='gfield_list_col_even' \/><col id='gfield_list_170_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Date : Last Physical<\/th><th>Date : Last Blood Work<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_170_cell1' data-label='Date : Last Physical'><input type='text' name='input_170[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_170_cell2' data-label='Date : Last Blood Work'><input type='text' name='input_170[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_171'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Energy<\/h2><\/li><li id='field_1_175'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >General Energy Levels<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_175'><li class='gchoice_1_175_0'><input name='input_175' type='radio' value='0-2 : Very Poor'  id='choice_1_175_0'     \/><label for='choice_1_175_0' id='label_1_175_0'>0-2 : Very Poor<\/label><\/li><li class='gchoice_1_175_1'><input name='input_175' type='radio' value='2-4 : Poor'  id='choice_1_175_1'     \/><label for='choice_1_175_1' id='label_1_175_1'>2-4 : Poor<\/label><\/li><li class='gchoice_1_175_2'><input name='input_175' type='radio' value='5-7 : Medium'  id='choice_1_175_2'     \/><label for='choice_1_175_2' id='label_1_175_2'>5-7 : Medium<\/label><\/li><li class='gchoice_1_175_3'><input name='input_175' type='radio' value='7-9 : Average'  id='choice_1_175_3'     \/><label for='choice_1_175_3' id='label_1_175_3'>7-9 : Average<\/label><\/li><li class='gchoice_1_175_4'><input name='input_175' type='radio' value='9-10 : Excellent'  id='choice_1_175_4'     \/><label for='choice_1_175_4' id='label_1_175_4'>9-10 : Excellent<\/label><\/li><\/ul><\/div><\/li><li id='field_1_174'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_174_shim' >Does your energy vary within a day?<\/label><div class='gfield_description'>If Yes, click the time(s) of day you feel is\/are best or worst for you<\/div><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_174_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_174 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_174_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_174_col_2' class='gfield_list_col_even' \/><col id='gfield_list_174_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_174_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Yes<\/th><th>Yes, best time of day<\/th><th>Yes, worst time of day<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_174_cell1' data-label='Yes'><select title='Yes'name='input_174[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_174_cell2' data-label='Yes, best time of day'><select title='Yes, best time of day'name='input_174[]'   ><option value='Midnight - 01h00' >Midnight - 01h00<\/option><option value='01h00 - 03h00' >01h00 - 03h00<\/option><option value='03h00 - 05h00' >03h00 - 05h00<\/option><option value='05h00 - 07h00' >05h00 - 07h00<\/option><option value='07h00 - 09h00' >07h00 - 09h00<\/option><option value='09h00 - 11h00' >09h00 - 11h00<\/option><option value='11h00 - Lunch' >11h00 - Lunch<\/option><option value='13h00 - 15h00' >13h00 - 15h00<\/option><option value='15h00 - 17h00' >15h00 - 17h00<\/option><option value='17h00 - 19h00' >17h00 - 19h00<\/option><option value='19h00 - 21h00' >19h00 - 21h00<\/option><option value='21h00 - 23h00' >21h00 - 23h00<\/option><option value='23h00 - Midnight' >23h00 - Midnight<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_174_cell3' data-label='Yes, worst time of day'><select title='Yes, worst time of day'name='input_174[]'   ><option value='Midnight - 01h00' >Midnight - 01h00<\/option><option value='01h00 - 03h00' >01h00 - 03h00<\/option><option value='03h00 - 05h00' >03h00 - 05h00<\/option><option value='05h00 - 07h00' >05h00 - 07h00<\/option><option value='07h00 - 09h00' >07h00 - 09h00<\/option><option value='09h00 - 11h00' >09h00 - 11h00<\/option><option value='11h00 - Lunch' >11h00 - Lunch<\/option><option value='13h00 - 15h00' >13h00 - 15h00<\/option><option value='15h00 - 17h00' >15h00 - 17h00<\/option><option value='17h00 - 19h00' >17h00 - 19h00<\/option><option value='19h00 - 21h00' >19h00 - 21h00<\/option><option value='21h00 - 23h00' >21h00 - 23h00<\/option><option value='23h00 - Midnight' >23h00 - Midnight<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_176'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_176' >What lifts your energy levels?<\/label><div class='ginput_container ginput_container_text'><input name='input_176' id='input_1_176' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_177'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_177' >What weakens your energy levels?<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_1_177' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_189'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Sleep Patters<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_178'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_178_shim' >Sleep Patterns<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_178_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_178 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_178_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_178_col_2' class='gfield_list_col_even' \/><col id='gfield_list_178_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_178_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Sleep Well<\/th><th>Yes\/No<\/th><th>Explanation<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_178_cell1' data-label='Sleep Well'><select title='Sleep Well'name='input_178[]'   ><option value='Sleep Well (If no, specify)' >Sleep Well (If no, specify)<\/option><option value='Insomnia' >Insomnia<\/option><option value='Sleepy during the day' >Sleepy during the day<\/option><option value='Wake up at night' >Wake up at night<\/option><option value='Wake early in the morning' >Wake early in the morning<\/option><option value='Restless' >Restless<\/option><option value='Nightmares\/Dreams' >Nightmares\/Dreams<\/option><option value='Wake to use bathroom' >Wake to use bathroom<\/option><option value='Wake rested (If no, specify)' >Wake rested (If no, specify)<\/option><option value='' ><\/option><\/select><\/td><td class='gfield_list_cell gfield_list_178_cell2' data-label='Yes\/No'><select title='Yes\/No'name='input_178[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_178_cell3' data-label='Explanation'><input type='text' name='input_178[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_188'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_188_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_188_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_188 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_188_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_188_col_2' class='gfield_list_col_even' \/><col id='gfield_list_188_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_188_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Average hours of sleep per night<\/th><th>Hours<\/th><th>Explanation<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_188_cell1' data-label='Average hours of sleep per night'><input type='text' name='input_188[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_188_cell2' data-label='Hours'><select title='Hours'name='input_188[]'   ><option value='Very little' >Very little<\/option><option value='1-2 hours' >1-2 hours<\/option><option value='2-4 hours' >2-4 hours<\/option><option value='4-6 hours' >4-6 hours<\/option><option value='6-8 hours' >6-8 hours<\/option><option value='8-10 hours' >8-10 hours<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_188_cell3' data-label='Explanation'><input type='text' name='input_188[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_190'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Sweating<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_191'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_191_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_191_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_191 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_191_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_191_col_2' class='gfield_list_col_even' \/><col id='gfield_list_191_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_191_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Night Sweats<\/th><th>Yes\/No\/Past<\/th><th>Specify<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_191_cell1' data-label='Night Sweats'><select title='Night Sweats'name='input_191[]'   ><option value='Night Sweats' >Night Sweats<\/option><option value='Perspire Profusely' >Perspire Profusely<\/option><option value='Perspire very little' >Perspire very little<\/option><option value='Do not perspire' >Do not perspire<\/option><option value='Sweat with high fever' >Sweat with high fever<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_191_cell2' data-label='Yes\/No\/Past'><select title='Yes\/No\/Past'name='input_191[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_191_cell3' data-label='Specify'><input type='text' name='input_191[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_192'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Skin<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_193'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_193_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_193_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_193 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_193_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_193_col_2' class='gfield_list_col_even' \/><col id='gfield_list_193_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_193_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Eczema<\/th><th>Yes\/No\/Past<\/th><th>Specify<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_193_cell1' data-label='Eczema'><select title='Eczema'name='input_193[]'   ><option value='Eczema' >Eczema<\/option><option value='Psoriasis' >Psoriasis<\/option><option value='Rashes' >Rashes<\/option><option value='Hives' >Hives<\/option><option value='Inflamation' >Inflamation<\/option><option value='Infection' >Infection<\/option><option value='Growths' >Growths<\/option><option value='Changes in hair' >Changes in hair<\/option><option value='Changes in nails' >Changes in nails<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_193_cell2' data-label='Yes\/No\/Past'><select title='Yes\/No\/Past'name='input_193[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_193_cell3' data-label='Specify'><input type='text' name='input_193[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 10)' onkeypress='gformAddListItem(this, 10)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 10)' onkeypress='gformDeleteListItem(this, 10)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_194'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Head<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_195'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_195_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_195_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_195 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_195_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_195_col_2' class='gfield_list_col_even' \/><col id='gfield_list_195_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_195_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>Heavy (If yes, please specify)<\/th><th>Specify (If yes, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_195_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_195[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_195_cell2' data-label='Heavy (If yes, please specify)'><select title='Heavy (If yes, please specify)'name='input_195[]'   ><option value='Heavy' >Heavy<\/option><option value='Distending' >Distending<\/option><option value='Prickling' >Prickling<\/option><option value='Burning ' >Burning <\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_195_cell3' data-label='Specify (If yes, please elaborate)'><input type='text' name='input_195[]' value=''  \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_197'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Where does the pain occur<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_197'><li class='gchoice_1_197_0'><input name='input_197' type='radio' value='Forehead'  id='choice_1_197_0'     \/><label for='choice_1_197_0' id='label_1_197_0'>Forehead<\/label><\/li><li class='gchoice_1_197_1'><input name='input_197' type='radio' value='Temples'  id='choice_1_197_1'     \/><label for='choice_1_197_1' id='label_1_197_1'>Temples<\/label><\/li><li class='gchoice_1_197_2'><input name='input_197' type='radio' value='Back of Head'  id='choice_1_197_2'     \/><label for='choice_1_197_2' id='label_1_197_2'>Back of Head<\/label><\/li><li class='gchoice_1_197_3'><input name='input_197' type='radio' value='Top of Head'  id='choice_1_197_3'     \/><label for='choice_1_197_3' id='label_1_197_3'>Top of Head<\/label><\/li><li class='gchoice_1_197_4'><input name='input_197' type='radio' value='Eyes'  id='choice_1_197_4'     \/><label for='choice_1_197_4' id='label_1_197_4'>Eyes<\/label><\/li><li class='gchoice_1_197_5'><input name='input_197' type='radio' value='Behind Eyes'  id='choice_1_197_5'     \/><label for='choice_1_197_5' id='label_1_197_5'>Behind Eyes<\/label><\/li><\/ul><\/div><\/li><li id='field_1_198'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_198_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_198_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_198 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_198_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_198_col_2' class='gfield_list_col_even' \/><col id='gfield_list_198_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_198_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_198_cell1' data-label='Health Issue'><select title='Health Issue'name='input_198[]'   ><option value='Head Injury' >Head Injury<\/option><option value='Dizziness or Vertigo' >Dizziness or Vertigo<\/option><option value='Dandruff' >Dandruff<\/option><option value='Dry Scalp' >Dry Scalp<\/option><option value='Swollen Glands' >Swollen Glands<\/option><option value='Pain or Stiffness' >Pain or Stiffness<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_198_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_198[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_198_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_198[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_199'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Eyes<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_200'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_200_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_200_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_200 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_200_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_200_col_2' class='gfield_list_col_even' \/><col id='gfield_list_200_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_200_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_200_cell1' data-label='Health Issue'><select title='Health Issue'name='input_200[]'   ><option value='Glasses\/Contacts' >Glasses\/Contacts<\/option><option value='Impaired Vision' >Impaired Vision<\/option><option value='Eye Pain' >Eye Pain<\/option><option value='Tearing or or Dryness' >Tearing or or Dryness<\/option><option value='Red, Itching, Painful' >Red, Itching, Painful<\/option><option value='Double Vision' >Double Vision<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_200_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_200[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_200_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_200[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_201'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Ears<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_204'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_204_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_204_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_204 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_204_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_204_col_2' class='gfield_list_col_even' \/><col id='gfield_list_204_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_204_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_204_cell1' data-label='Health Issue'><select title='Health Issue'name='input_204[]'   ><option value='Hearing Loss' >Hearing Loss<\/option><option value='Impaired Hearing' >Impaired Hearing<\/option><option value='Ringing' >Ringing<\/option><option value='Earache\/Itch' >Earache\/Itch<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_204_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_204[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_204_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_204[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_203'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Nose &amp; Sinuses<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_206'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_206_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_206_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_206 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_206_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_206_col_2' class='gfield_list_col_even' \/><col id='gfield_list_206_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_206_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_206_cell1' data-label='Health Issue'><select title='Health Issue'name='input_206[]'   ><option value='Frequent Colds' >Frequent Colds<\/option><option value='Nose Bleeds' >Nose Bleeds<\/option><option value='Stuffiness' >Stuffiness<\/option><option value='Sinus Problems' >Sinus Problems<\/option><option value='Post Nasal Drip' >Post Nasal Drip<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_206_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_206[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_206_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_206[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 6)' onkeypress='gformAddListItem(this, 6)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 6)' onkeypress='gformDeleteListItem(this, 6)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_205'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Mouth &amp; Throat<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_202'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_202_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_202_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_202 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_202_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_202_col_2' class='gfield_list_col_even' \/><col id='gfield_list_202_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_202_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_202_cell1' data-label='Health Issue'><select title='Health Issue'name='input_202[]'   ><option value='Frequent Sore Throats' >Frequent Sore Throats<\/option><option value='Sore Tongue' >Sore Tongue<\/option><option value='Sores in Mouth\/On Lips' >Sores in Mouth\/On Lips<\/option><option value='Gum Problems\/Bleeding' >Gum Problems\/Bleeding<\/option><option value='Hoarseness' >Hoarseness<\/option><option value='Jaw Pain' >Jaw Pain<\/option><option value='Dental Problems' >Dental Problems<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_202_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_202[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_202_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_202[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 8)' onkeypress='gformAddListItem(this, 8)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 8)' onkeypress='gformDeleteListItem(this, 8)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_207'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Respiratory\/Chest<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_209'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_209_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_209_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_209 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_209_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_209_col_2' class='gfield_list_col_even' \/><col id='gfield_list_209_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_209_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>Area of Pain<\/th><th>Specify (If yes, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_209_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_209[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_209_cell2' data-label='Area of Pain'><select title='Area of Pain'name='input_209[]'   ><option value='Sides' >Sides<\/option><option value='Central Chest' >Central Chest<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_209_cell3' data-label='Specify (If yes, please elaborate)'><select title='Specify (If yes, please elaborate)'name='input_209[]'   ><option value='Burning' >Burning<\/option><option value='Prickling' >Prickling<\/option><option value='Distending' >Distending<\/option><option value='Dull' >Dull<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_208'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_208_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_208_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_208 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_208_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_208_col_2' class='gfield_list_col_even' \/><col id='gfield_list_208_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_208_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_208_cell1' data-label='Health Issue'><select title='Health Issue'name='input_208[]'   ><option value='Cough' >Cough<\/option><option value='Wheezing' >Wheezing<\/option><option value='Spitting up blood' >Spitting up blood<\/option><option value='Difficulty breathing' >Difficulty breathing<\/option><option value='Pain when breathing' >Pain when breathing<\/option><option value='Shortness of breath' >Shortness of breath<\/option><option value='Shortness of breath on lying down' >Shortness of breath on lying down<\/option><option value='Shortness of breath at night' >Shortness of breath at night<\/option><option value='Positive Tuberculosis Test' >Positive Tuberculosis Test<\/option><option value='Asthma' >Asthma<\/option><option value='Hay Fever' >Hay Fever<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_208_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_208[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_208_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_208[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 8)' onkeypress='gformAddListItem(this, 8)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 8)' onkeypress='gformDeleteListItem(this, 8)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_210'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Heart<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_211'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_211_shim' >Chest Pain<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_211_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_211 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_211_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_211_col_2' class='gfield_list_col_even' \/><col id='gfield_list_211_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>Specify (If yes, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_211_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_211[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_211_cell2' data-label='Specify (If yes, please elaborate)'><select title='Specify (If yes, please elaborate)'name='input_211[]'   ><option value='Burning' >Burning<\/option><option value='Prickling' >Prickling<\/option><option value='Fullness' >Fullness<\/option><option value='Tightness' >Tightness<\/option><option value='Distending' >Distending<\/option><option value='Dull' >Dull<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_212'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_212_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_212_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_212 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_212_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_212_col_2' class='gfield_list_col_even' \/><col id='gfield_list_212_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_212_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_212_cell1' data-label='Health Issue'><select title='Health Issue'name='input_212[]'   ><option value='Heart Disease' >Heart Disease<\/option><option value='High Blood Pressure' >High Blood Pressure<\/option><option value='Rheumatic Fever' >Rheumatic Fever<\/option><option value='Swelling in Legs\/Ankles' >Swelling in Legs\/Ankles<\/option><option value='Palpitation\/Fluttering' >Palpitation\/Fluttering<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_212_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_212[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_212_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_212[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 6)' onkeypress='gformAddListItem(this, 6)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 6)' onkeypress='gformDeleteListItem(this, 6)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_213'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Digestion\/Abdomen<\/h2><div class='gsection_description'>If yes or past, please explain below<\/div><\/li><li id='field_1_214'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_214_shim' >Stomach\/Abdominal Pain<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_214_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_214 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_214_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_214_col_2' class='gfield_list_col_even' \/><col id='gfield_list_214_col_3' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>Specify (If yes, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_214_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_214[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_214_cell2' data-label='Specify (If yes, please elaborate)'><select title='Specify (If yes, please elaborate)'name='input_214[]'   ><option value='Cramping' >Cramping<\/option><option value='Prickling' >Prickling<\/option><option value='Fullness' >Fullness<\/option><option value='Distending' >Distending<\/option><option value='Dull' >Dull<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 6)' onkeypress='gformAddListItem(this, 6)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 6)' onkeypress='gformDeleteListItem(this, 6)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_216'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Pain Is Relieved By ...<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_216'><li class='gchoice_1_216_0'><input name='input_216' type='radio' value='Pressure'  id='choice_1_216_0'     \/><label for='choice_1_216_0' id='label_1_216_0'>Pressure<\/label><\/li><li class='gchoice_1_216_1'><input name='input_216' type='radio' value='Heat'  id='choice_1_216_1'     \/><label for='choice_1_216_1' id='label_1_216_1'>Heat<\/label><\/li><li class='gchoice_1_216_2'><input name='input_216' type='radio' value='Cold'  id='choice_1_216_2'     \/><label for='choice_1_216_2' id='label_1_216_2'>Cold<\/label><\/li><li class='gchoice_1_216_3'><input name='input_216' type='radio' value='Bowel Movement'  id='choice_1_216_3'     \/><label for='choice_1_216_3' id='label_1_216_3'>Bowel Movement<\/label><\/li><\/ul><\/div><\/li><li id='field_1_215'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_215_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_215_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_215 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_215_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_215_col_2' class='gfield_list_col_even' \/><col id='gfield_list_215_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_215_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_215_cell1' data-label='Health Issue'><select title='Health Issue'name='input_215[]'   ><option value='Trouble Swallowing' >Trouble Swallowing<\/option><option value='Heartburn' >Heartburn<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_215_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_215[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_215_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_215[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 2)' onkeypress='gformAddListItem(this, 2)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 2)' onkeypress='gformDeleteListItem(this, 2)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_217'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label'  >Change in Thirst<\/label><div class='gfield_description'>Do You Prefer <\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_217'><li class='gchoice_1_217_0'><input name='input_217' type='radio' value='Hot'  id='choice_1_217_0'     \/><label for='choice_1_217_0' id='label_1_217_0'>Hot<\/label><\/li><li class='gchoice_1_217_1'><input name='input_217' type='radio' value='Cold'  id='choice_1_217_1'     \/><label for='choice_1_217_1' id='label_1_217_1'>Cold<\/label><\/li><li class='gchoice_1_217_2'><input name='input_217' type='radio' value='Not Thirsty'  id='choice_1_217_2'     \/><label for='choice_1_217_2' id='label_1_217_2'>Not Thirsty<\/label><\/li><li class='gchoice_1_217_3'><input name='input_217' type='radio' value='Other'  id='choice_1_217_3'     \/><label for='choice_1_217_3' id='label_1_217_3'>Other<\/label><\/li><\/ul><\/div><\/li><li id='field_1_219'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_219_shim' >Change in Appetite<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_219_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_219 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_219_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_219_col_2' class='gfield_list_col_even' \/><col id='gfield_list_219_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_219_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>No\/Yes<\/th><th>If yes, describe<\/th><th>Taste\/Feeling in Mouth<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_219_cell1' data-label='No\/Yes'><select title='No\/Yes'name='input_219[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_219_cell2' data-label='If yes, describe'><select title='If yes, describe'name='input_219[]'   ><option value='None' >None<\/option><option value='Abnormal' >Abnormal<\/option><option value='Over Eating' >Over Eating<\/option><option value='Under Eating' >Under Eating<\/option><option value='Hungry, yet cannot eat' >Hungry, yet cannot eat<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_219_cell3' data-label='Taste\/Feeling in Mouth'><select title='Taste\/Feeling in Mouth'name='input_219[]'   ><option value='None' >None<\/option><option value='Bland' >Bland<\/option><option value='Sour' >Sour<\/option><option value='Salty' >Salty<\/option><option value='Hot' >Hot<\/option><option value='Sweet ' >Sweet <\/option><option value='Bitter' >Bitter<\/option><option value='Sticky' >Sticky<\/option><option value='Metallic' >Metallic<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_218'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_218_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_218_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_218 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_218_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_218_col_2' class='gfield_list_col_even' \/><col id='gfield_list_218_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_218_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_218_cell1' data-label='Health Issue'><select title='Health Issue'name='input_218[]'   ><option value='Nausea' >Nausea<\/option><option value='Vomiting' >Vomiting<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_218_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_218[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_218_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_218[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 2)' onkeypress='gformAddListItem(this, 2)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 2)' onkeypress='gformDeleteListItem(this, 2)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_220'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label'  >Belching\/Gas\/Bloating<\/label><div class='gfield_description'>Do these symptoms occur ...<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_220'><li class='gchoice_1_220_0'><input name='input_220' type='radio' value='During meals'  id='choice_1_220_0'     \/><label for='choice_1_220_0' id='label_1_220_0'>During meals<\/label><\/li><li class='gchoice_1_220_1'><input name='input_220' type='radio' value='1 hour after meals'  id='choice_1_220_1'     \/><label for='choice_1_220_1' id='label_1_220_1'>1 hour after meals<\/label><\/li><li class='gchoice_1_220_2'><input name='input_220' type='radio' value='2-3 hours after meals'  id='choice_1_220_2'     \/><label for='choice_1_220_2' id='label_1_220_2'>2-3 hours after meals<\/label><\/li><li class='gchoice_1_220_3'><input name='input_220' type='radio' value='Other'  id='choice_1_220_3'     \/><label for='choice_1_220_3' id='label_1_220_3'>Other<\/label><\/li><\/ul><\/div><\/li><li id='field_1_222'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_222_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_222_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_222 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_222_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_222_col_2' class='gfield_list_col_even' \/><col id='gfield_list_222_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_222_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_222_cell1' data-label='Health Issue'><select title='Health Issue'name='input_222[]'   ><option value='Heaviness from foods' >Heaviness from foods<\/option><option value='Liver\/gall bladder disease' >Liver\/gall bladder disease<\/option><option value='Gall stones' >Gall stones<\/option><option value='High Cholesterol' >High Cholesterol<\/option><option value='Diabetes' >Diabetes<\/option><option value='Mononucleosis' >Mononucleosis<\/option><option value='Ulcers' >Ulcers<\/option><option value='Pain before eating' >Pain before eating<\/option><option value='Pain after eating' >Pain after eating<\/option><option value='Low Blood Sugar\/Hypoglycemia' >Low Blood Sugar\/Hypoglycemia<\/option><option value='Irritable before meals' >Irritable before meals<\/option><option value='Tired after eating' >Tired after eating<\/option><option value='Distress from fats\/greasy foods (nausea, dizziness, headaches)' >Distress from fats\/greasy foods (nausea, dizziness, headaches)<\/option><option value='Rapid weight change' >Rapid weight change<\/option><option value='Hiccups' >Hiccups<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_222_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_222[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_222_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_222[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 2)' onkeypress='gformAddListItem(this, 2)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 2)' onkeypress='gformDeleteListItem(this, 2)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_223'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Bowel Function<\/h2><\/li><li id='field_1_224'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_224_shim' >Frequency of Bowel Movements<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_224_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_224 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_224_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_224_col_2' class='gfield_list_col_even' \/><col id='gfield_list_224_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_224_col_4' class='gfield_list_col_even' \/><col id='gfield_list_224_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Times<\/th><th>Per Day\/Per Week<\/th><th>Usual Time<\/th><th>Consistency of Bowel Movements<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_224_cell1' data-label='Times'><input type='text' name='input_224[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_224_cell2' data-label='Per Day\/Per Week'><select title='Per Day\/Per Week'name='input_224[]'   ><option value='Per Day' >Per Day<\/option><option value='Per Week' >Per Week<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_224_cell3' data-label='Usual Time'><input type='text' name='input_224[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_224_cell4' data-label='Consistency of Bowel Movements'><select title='Consistency of Bowel Movements'name='input_224[]'   ><option value='Regular' >Regular<\/option><option value='Constipated' >Constipated<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_225'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_225_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_225_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_225 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_225_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_225_col_2' class='gfield_list_col_even' \/><col id='gfield_list_225_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_225_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_225_cell1' data-label='Health Issue'><select title='Health Issue'name='input_225[]'   ><option value='Diarrhea' >Diarrhea<\/option><option value='Constipation' >Constipation<\/option><option value='Alternate diarrhea &amp; constipation' >Alternate diarrhea &amp; constipation<\/option><option value='Loose\/broken stools' >Loose\/broken stools<\/option><option value='Stools hard to pass' >Stools hard to pass<\/option><option value='Blood\/Mucus in stools' >Blood\/Mucus in stools<\/option><option value='Undigested Food in Stool' >Undigested Food in Stool<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_225_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_225[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_225_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_225[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 7)' onkeypress='gformAddListItem(this, 7)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 7)' onkeypress='gformDeleteListItem(this, 7)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_226'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Urinary Function<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_229'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_229_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_229_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_229 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_229_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_229_col_2' class='gfield_list_col_even' \/><col id='gfield_list_229_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_229_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_229_cell1' data-label='Health Issue'><select title='Health Issue'name='input_229[]'   ><option value='Pain on urination' >Pain on urination<\/option><option value='Burning on urination' >Burning on urination<\/option><option value='Increased frequency' >Increased frequency<\/option><option value='Frequency at night' >Frequency at night<\/option><option value='Change in colour' >Change in colour<\/option><option value='Change in odor' >Change in odor<\/option><option value='Unable to hold urine' >Unable to hold urine<\/option><option value='Incomplete urination' >Incomplete urination<\/option><option value='Bladder infections' >Bladder infections<\/option><option value='Kidney stones' >Kidney stones<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_229_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_229[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_229_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_229[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 10)' onkeypress='gformAddListItem(this, 10)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 10)' onkeypress='gformDeleteListItem(this, 10)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_228'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Circulation<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_227'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_227_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_227_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_227 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_227_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_227_col_2' class='gfield_list_col_even' \/><col id='gfield_list_227_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_227_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_227_cell1' data-label='Health Issue'><select title='Health Issue'name='input_227[]'   ><option value='Deep leg pain' >Deep leg pain<\/option><option value='Cold hands\/feet' >Cold hands\/feet<\/option><option value='Varicose veins' >Varicose veins<\/option><option value='Hemorrhoids' >Hemorrhoids<\/option><option value='Anemia' >Anemia<\/option><option value='Easy bleeding\/bruising' >Easy bleeding\/bruising<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_227_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_227[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_227_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_227[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 10)' onkeypress='gformAddListItem(this, 10)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 10)' onkeypress='gformDeleteListItem(this, 10)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_230'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Neurological<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_231'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_231_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_231_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_231 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_231_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_231_col_2' class='gfield_list_col_even' \/><col id='gfield_list_231_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_231_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_231_cell1' data-label='Health Issue'><select title='Health Issue'name='input_231[]'   ><option value='Fainting' >Fainting<\/option><option value='Seizures' >Seizures<\/option><option value='Paralysis' >Paralysis<\/option><option value='Muscle weakness' >Muscle weakness<\/option><option value='Memory loss' >Memory loss<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_231_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_231[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_231_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_231[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_232'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Sexual Function<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_233'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_233_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_233_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_233 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_233_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_233_col_2' class='gfield_list_col_even' \/><col id='gfield_list_233_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_233_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_233_cell1' data-label='Health Issue'><select title='Health Issue'name='input_233[]'   ><option value='Change in libido' >Change in libido<\/option><option value='Loss of libido' >Loss of libido<\/option><option value='Infertility' >Infertility<\/option><option value='Venereal disease' >Venereal disease<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_233_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_233[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_233_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_233[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_234'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Female Reproduction<\/h2><\/li><li id='field_1_236'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_236_shim' >Details<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_236_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_236 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_236_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_236_col_2' class='gfield_list_col_even' \/><col id='gfield_list_236_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_236_col_4' class='gfield_list_col_even' \/><col id='gfield_list_236_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_236_col_6' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Age Menses Began<\/th><th>Date of Last Menstruation<\/th><th>No of days of Menstrual Flow<\/th><th>Length of Complete Cycle<\/th><th>Regular Self Breast Exam<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_236_cell1' data-label='Age Menses Began'><input type='text' name='input_236[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_236_cell2' data-label='Date of Last Menstruation'><input type='text' name='input_236[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_236_cell3' data-label='No of days of Menstrual Flow'><input type='text' name='input_236[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_236_cell4' data-label='Length of Complete Cycle'><input type='text' name='input_236[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_236_cell5' data-label='Regular Self Breast Exam'><select title='Regular Self Breast Exam'name='input_236[]'   ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_237'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_237_shim' >Details<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_237_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_237 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_237_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_237_col_2' class='gfield_list_col_even' \/><col id='gfield_list_237_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_237_col_4' class='gfield_list_col_even' \/><col id='gfield_list_237_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_237_col_6' class='gfield_list_col_even' \/><col id='gfield_list_237_col_7' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Date &amp; Results of last PAP<\/th><th>Abnormal PAP<\/th><th>No of Pregnancies<\/th><th>No of Live Births<\/th><th>No of Miscarriages<\/th><th>No of Abortions<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_237_cell1' data-label='Date &amp; Results of last PAP'><input type='text' name='input_237[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_237_cell2' data-label='Abnormal PAP'><select title='Abnormal PAP'name='input_237[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_237_cell3' data-label='No of Pregnancies'><select title='No of Pregnancies'name='input_237[]'   ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='More' >More<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_237_cell4' data-label='No of Live Births'><select title='No of Live Births'name='input_237[]'   ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='More' >More<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_237_cell5' data-label='No of Miscarriages'><select title='No of Miscarriages'name='input_237[]'   ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='More' >More<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_237_cell6' data-label='No of Abortions'><select title='No of Abortions'name='input_237[]'   ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='More' >More<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_235'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_235_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_235_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_235 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_235_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_235_col_2' class='gfield_list_col_even' \/><col id='gfield_list_235_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_235_col_4' class='gfield_list_col_even' \/><col id='gfield_list_235_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Sexually Active<\/th><th>Birth Control<\/th><th>Spotting Between Periods<\/th><th>Are Cycles Regular<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_235_cell1' data-label='Sexually Active'><select title='Sexually Active'name='input_235[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_235_cell2' data-label='Birth Control'><select title='Birth Control'name='input_235[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_235_cell3' data-label='Spotting Between Periods'><select title='Spotting Between Periods'name='input_235[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_235_cell4' data-label='Are Cycles Regular'><select title='Are Cycles Regular'name='input_235[]'   ><option value='Yes' >Yes<\/option><option value='Early' >Early<\/option><option value='Delayed' >Delayed<\/option><option value='Irregular' >Irregular<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 4)' onkeypress='gformAddListItem(this, 4)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 4)' onkeypress='gformDeleteListItem(this, 4)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_238'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_238_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_238_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_238 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_238_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_238_col_2' class='gfield_list_col_even' \/><col id='gfield_list_238_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_238_col_4' class='gfield_list_col_even' \/><col id='gfield_list_238_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Pain During Intercourse<\/th><th>Cramps\/Period Pains<\/th><th>Are Cycles Regular?<\/th><th>Abnormal Vaginal Discharge<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_238_cell1' data-label='Pain During Intercourse'><select title='Pain During Intercourse'name='input_238[]'   ><option value='No' >No<\/option><option value='yes' >yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_238_cell2' data-label='Cramps\/Period Pains'><select title='Cramps\/Period Pains'name='input_238[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_238_cell3' data-label='Are Cycles Regular?'><select title='Are Cycles Regular?'name='input_238[]'   ><option value='Yes' >Yes<\/option><option value='Early' >Early<\/option><option value='Delayed' >Delayed<\/option><option value='Irregular' >Irregular<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_238_cell4' data-label='Abnormal Vaginal Discharge'><select title='Abnormal Vaginal Discharge'name='input_238[]'   ><option value='No' >No<\/option><option value='Yellow' >Yellow<\/option><option value='White' >White<\/option><option value='Thick' >Thick<\/option><option value='Strong odor' >Strong odor<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 4)' onkeypress='gformAddListItem(this, 4)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 4)' onkeypress='gformDeleteListItem(this, 4)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_239'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_239_shim' >Select one or more by adding a row (+)<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_239_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_239 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_239_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_239_col_2' class='gfield_list_col_even' \/><col id='gfield_list_239_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_239_col_4' class='gfield_list_col_even' \/><col id='gfield_list_239_col_5' class='gfield_list_col_odd' \/><\/colgroup><thead><tr><th>Vaginal Infections<\/th><th>Menstrual Flow<\/th><th>Colour of Flow<\/th><th>Consistency of Flow<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_239_cell1' data-label='Vaginal Infections'><select title='Vaginal Infections'name='input_239[]'   ><option value='No' >No<\/option><option value='yes' >yes<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_239_cell2' data-label='Menstrual Flow'><select title='Menstrual Flow'name='input_239[]'   ><option value='Normal' >Normal<\/option><option value='Heavy' >Heavy<\/option><option value='Light' >Light<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_239_cell3' data-label='Colour of Flow'><select title='Colour of Flow'name='input_239[]'   ><option value='Normal' >Normal<\/option><option value='Bright red' >Bright red<\/option><option value='Dark red' >Dark red<\/option><option value='Light red' >Light red<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_239_cell4' data-label='Consistency of Flow'><select title='Consistency of Flow'name='input_239[]'   ><option value='Thin' >Thin<\/option><option value='Thick' >Thick<\/option><option value='Clotted' >Clotted<\/option><\/select><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 4)' onkeypress='gformAddListItem(this, 4)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 4)' onkeypress='gformDeleteListItem(this, 4)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_241'  class='gfield field_sublabel_below field_description_above gfield_visibility_visible' ><label class='gfield_label' for='input_1_241' >PMS<\/label><div class='gfield_description'>Multiple selection option<\/div><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_241[]' id='input_1_241'  class='medium gfield_select'  ><option value='Breast tenderness' >Breast tenderness<\/option><option value='Moods' >Moods<\/option><option value='Water retention' >Water retention<\/option><option value='Headaches' >Headaches<\/option><option value='Cravings' >Cravings<\/option><option value='Backache' >Backache<\/option><option value='Acne' >Acne<\/option><option value='Bloating' >Bloating<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id='field_1_242'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_242_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_242_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_242 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_242_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_242_col_2' class='gfield_list_col_even' \/><col id='gfield_list_242_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_242_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_242_cell1' data-label='Health Issue'><select title='Health Issue'name='input_242[]'   ><option value='Ovarian Cysts' >Ovarian Cysts<\/option><option value='Uterine Fibroids' >Uterine Fibroids<\/option><option value='Difficulty Conceiving' >Difficulty Conceiving<\/option><option value='Menopausal Symptoms' >Menopausal Symptoms<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_242_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_242[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_242_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_242[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_243'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Male Reproduction<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_245'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_1_245' >Date and results of most recent rectal exam for an enlarged prostrate<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_1_245' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_1_244'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_244_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_244_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_244 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_244_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_244_col_2' class='gfield_list_col_even' \/><col id='gfield_list_244_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_244_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_244_cell1' data-label='Health Issue'><select title='Health Issue'name='input_244[]'   ><option value='Impotence' >Impotence<\/option><option value='Premature ejaculation' >Premature ejaculation<\/option><option value='Noctural emissions' >Noctural emissions<\/option><option value='Hernias' >Hernias<\/option><option value='Testicular masses' >Testicular masses<\/option><option value='Testicular pain' >Testicular pain<\/option><option value='Are you sexually active' >Are you sexually active<\/option><option value='Sexual difficulties' >Sexual difficulties<\/option><option value='Any prostate problems' >Any prostate problems<\/option><option value='Discharge\/Sores' >Discharge\/Sores<\/option><option value='Difficulty starting\/stopping urination' >Difficulty starting\/stopping urination<\/option><option value='Birth control' >Birth control<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_244_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_244[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_244_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_244[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_246'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Risk of Infection<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_247'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_247_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_247_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_247 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_247_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_247_col_2' class='gfield_list_col_even' \/><col id='gfield_list_247_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_247_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_247_cell1' data-label='Health Issue'><select title='Health Issue'name='input_247[]'   ><option value='HIV\/Aids' >HIV\/Aids<\/option><option value='Hepatitis B' >Hepatitis B<\/option><option value='Hepatitis C' >Hepatitis C<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_247_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_247[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_247_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_247[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_248'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Emotional<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_249'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_249_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_249_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_249 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_249_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_249_col_2' class='gfield_list_col_even' \/><col id='gfield_list_249_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_249_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_249_cell1' data-label='Health Issue'><select title='Health Issue'name='input_249[]'   ><option value='Mood swings' >Mood swings<\/option><option value='Depression' >Depression<\/option><option value='Anger\/Resentment' >Anger\/Resentment<\/option><option value='Anxiety\/Nervousness' >Anxiety\/Nervousness<\/option><option value='Fear' >Fear<\/option><option value='Feeling of helplessness' >Feeling of helplessness<\/option><option value='Apathy' >Apathy<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_249_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_249[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_249_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_249[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_250'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Musculoskeletal<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_251'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_251_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_251_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_251 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_251_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_251_col_2' class='gfield_list_col_even' \/><col id='gfield_list_251_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_251_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_251_cell1' data-label='Health Issue'><select title='Health Issue'name='input_251[]'   ><option value='Joint Pain\/Stiffness' >Joint Pain\/Stiffness<\/option><option value='Muscle Pain\/Stiffness' >Muscle Pain\/Stiffness<\/option><option value='Muscle Spasms\/Cramps' >Muscle Spasms\/Cramps<\/option><option value='Lower back pain' >Lower back pain<\/option><option value='Numbness\/Tingling' >Numbness\/Tingling<\/option><option value='Arthritis' >Arthritis<\/option><option value='Broken bones' >Broken bones<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_251_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_251[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_251_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_251[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_252'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Miscellaneous<\/h2><div class='gsection_description'>Select one or more by adding a row (+)<\/div><\/li><li id='field_1_253'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_253_shim' ><\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_253_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_253 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_253_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_253_col_2' class='gfield_list_col_even' \/><col id='gfield_list_253_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_253_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Health Issue<\/th><th>No\/Yes\/Past<\/th><th>Specify (If yes or past, please elaborate)<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_253_cell1' data-label='Health Issue'><select title='Health Issue'name='input_253[]'   ><option value='Thyroid problems' >Thyroid problems<\/option><option value='Heat intolerance' >Heat intolerance<\/option><option value='Cold intolerance' >Cold intolerance<\/option><option value='Fever' >Fever<\/option><option value='Chills' >Chills<\/option><option value='Alternating chills &amp; fever' >Alternating chills &amp; fever<\/option><option value='Body feels cold' >Body feels cold<\/option><option value='Easy weight gain' >Easy weight gain<\/option><option value='Rapid weight change' >Rapid weight change<\/option><option value='Dizzy upon standing\/bending' >Dizzy upon standing\/bending<\/option><option value='Fluoride toothpaste' >Fluoride toothpaste<\/option><option value='Drink tap water' >Drink tap water<\/option><option value='Other' >Other<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_253_cell2' data-label='No\/Yes\/Past'><select title='No\/Yes\/Past'name='input_253[]'   ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><option value='Past' >Past<\/option><\/select><\/td><td class='gfield_list_cell gfield_list_253_cell3' data-label='Specify (If yes or past, please elaborate)'><input type='text' name='input_253[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 5)' onkeypress='gformAddListItem(this, 5)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 5)' onkeypress='gformDeleteListItem(this, 5)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_257'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Stressors &amp; Symptoms<\/h2><div class='gsection_description'>Using the timeline below, list the stressors (surgery, accidents\/injury, change in work\/residence\/relationships,\nbirths, loss, mental\/emotional stress etc) and symptoms (pain, digestive concerns, fatigue, headaches, allergies,\nmenstrual changes, behavior\/mood changes, etc)<\/div><\/li><li id='field_1_255'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_255_shim' >STRESSORS<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_255_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_255 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_255_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_255_col_2' class='gfield_list_col_even' \/><col id='gfield_list_255_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_255_col_4' class='gfield_list_col_even' \/><col id='gfield_list_255_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_255_col_6' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Pre-Natal<\/th><th>Birth<\/th><th>Childhood<\/th><th>Adolescence<\/th><th>Adulthood<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_255_cell1' data-label='Pre-Natal'><input type='text' name='input_255[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_255_cell2' data-label='Birth'><input type='text' name='input_255[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_255_cell3' data-label='Childhood'><input type='text' name='input_255[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_255_cell4' data-label='Adolescence'><input type='text' name='input_255[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_255_cell5' data-label='Adulthood'><input type='text' name='input_255[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_256'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' for='input_1_256_shim' >SYMPTOMS<\/label><div class='ginput_container ginput_container_list ginput_list'><input type='text' id='input_1_256_shim' style='position:absolute;left:-999em;' onfocus='jQuery( \"#field_1_256 table tr td:first-child input\" ).focus();' \/><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_256_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_256_col_2' class='gfield_list_col_even' \/><col id='gfield_list_256_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_256_col_4' class='gfield_list_col_even' \/><col id='gfield_list_256_col_5' class='gfield_list_col_odd' \/><col id='gfield_list_256_col_6' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th>Pre-Natal<\/th><th>Birth<\/th><th>Childhood<\/th><th>Adolescence<\/th><th>Adulthood<\/th><th>&nbsp;<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_256_cell1' data-label='Pre-Natal'><input type='text' name='input_256[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_256_cell2' data-label='Birth'><input type='text' name='input_256[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_256_cell3' data-label='Childhood'><input type='text' name='input_256[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_256_cell4' data-label='Adolescence'><input type='text' name='input_256[]' value=''  \/><\/td><td class='gfield_list_cell gfield_list_256_cell5' data-label='Adulthood'><input type='text' name='input_256[]' value=''  \/><\/td><td class='gfield_list_icons'>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' class='add_list_item '  title='Add another row' alt='Add a new row' onclick='gformAddListItem(this, 0)' onkeypress='gformAddListItem(this, 0)' style='cursor:pointer;' \/>   <img src=\"data:image\/svg+xml,%3Csvg%20xmlns%3D&#39;http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg&#39;%20width=&#39;_w_&#39;%20height=&#39;_h_&#39;%20viewBox%3D&#39;0%200%20_w_%20_h_&#39;%2F%3E\" data-czlz data-src='https:\/\/drsusanjanssens.com\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' class='delete_list_item'  title='Remove this row' alt='Remove this row' onclick='gformDeleteListItem(this, 0)' onkeypress='gformDeleteListItem(this, 0)' style='cursor:pointer; visibility:hidden;' \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id='field_1_254'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Neurotransmitter Questionnaire<\/h2><div class='gsection_description'>In the questionnaire that follows, read each statement and score it in the margin as follows:\n* 0 points if this statement is not true at or does not apply to you.\n* 1 point if the statement is true a lot of the time and\/or is affecting the quality of your life.\nPlease respond to all questions as though you were not taking any medications or supplements.<\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  window[\"gf_submitting_1\"]=true;  ' 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