{"id":135985,"date":"2023-12-29T18:50:19","date_gmt":"2023-12-29T18:50:19","guid":{"rendered":"https:\/\/clinicmono.com\/formulaire-de-bilan-de-sante-obesite\/"},"modified":"2024-07-25T14:13:12","modified_gmt":"2024-07-25T14:13:12","slug":"formulaire-de-bilan-de-sante-obesite","status":"publish","type":"page","link":"https:\/\/clinicmono.com\/fr\/formulaire-de-bilan-de-sante-obesite\/","title":{"rendered":"Formulaire de bilan de sant\u00e9 Ob\u00e9sit\u00e9"},"content":{"rendered":"<section class=\"l-section wpb_row height_custom with_img\"><div class=\"l-section-img\" role=\"img\" data-img-width=\"1920\" data-img-height=\"400\" style=\"background-image: url(https:\/\/clinicmono.com\/wp-content\/uploads\/2023\/05\/call1.jpg);background-repeat: no-repeat;background-size: auto;\"><\/div><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h1 style=\"text-align: center;\">Formulaire de bilan de sant\u00e9 Ob\u00e9sit\u00e9<\/h1>\n<\/div><\/div><nav class=\"g-breadcrumbs separator_icon align_center\" itemscope itemtype=\"http:\/\/schema.org\/BreadcrumbList\"><div class=\"g-breadcrumbs-item\" itemscope itemprop=\"itemListElement\" itemtype=\"http:\/\/schema.org\/ListItem\"><a itemprop=\"item\" href=\"https:\/\/clinicmono.com\/fr\/\"><span itemprop=\"name\">Clinique Mono<\/span><\/a><meta itemprop=\"position\" content=\"1\"\/><\/div><div class=\"g-breadcrumbs-separator\"><i class=\"far fa-angle-double-right\"><\/i><\/div><div class=\"g-breadcrumbs-item\">Pages<\/div><\/nav><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_custom\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"g-cols wpb_row hide_on_tablets hide_on_mobiles via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpforms-container wpforms-render-modern\" id=\"wpforms-42102\"><form id=\"wpforms-form-42102\" class=\"wpforms-validate wpforms-form\" data-formid=\"42102\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/135985\" data-token=\"ce89f54860ff8bbd74076064193c4115\" data-token-time=\"1775993802\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-42102-field_1-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_1\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-42102-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"Name\" aria-errormessage=\"wpforms-42102-field_1-error\" required><\/div><div id=\"wpforms-42102-field_70-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_70\">Surname <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-42102-field_70\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][70]\" placeholder=\"Surname\" aria-errormessage=\"wpforms-42102-field_70-error\" required><\/div><div id=\"wpforms-42102-field_4-container\" class=\"wpforms-field wpforms-field-email wpforms-one-fourth\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-42102-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" placeholder=\"Email\" spellcheck=\"false\" aria-errormessage=\"wpforms-42102-field_4-error\" required><\/div><div id=\"wpforms-42102-field_132-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"132\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_132\">Birthday <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-42102-field_132\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-42102-field_132-error\" required><\/div><div id=\"wpforms-42102-field_75-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_75\">Occupation<\/label><input type=\"text\" id=\"wpforms-42102-field_75\" class=\"wpforms-field-large\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-42102-field_75-error\" ><\/div><div id=\"wpforms-42102-field_76-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_76\">Height<\/label><input type=\"text\" id=\"wpforms-42102-field_76\" class=\"wpforms-field-large\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-42102-field_76-error\" ><\/div><div id=\"wpforms-42102-field_77-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_77\">Weight<\/label><input type=\"text\" id=\"wpforms-42102-field_77\" class=\"wpforms-field-large\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-42102-field_77-error\" ><\/div><div id=\"wpforms-42102-field_78-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_78\">BMI Index<\/label><input type=\"text\" id=\"wpforms-42102-field_78\" class=\"wpforms-field-large\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-42102-field_78-error\" ><\/div><div id=\"wpforms-42102-field_79-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-first\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_79\">Country<\/label><input type=\"text\" id=\"wpforms-42102-field_79\" class=\"wpforms-field-large\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-42102-field_79-error\" ><\/div><div id=\"wpforms-42102-field_3-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-third\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_3\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-42102-field_3\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" placeholder=\"Phone Number\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-42102-field_3-error\" required><\/div><div id=\"wpforms-42102-field_82-container\" class=\"wpforms-field wpforms-field-text wpforms-first\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_82\">Address<\/label><input type=\"text\" id=\"wpforms-42102-field_82\" class=\"wpforms-field-large\" name=\"wpforms[fields][82]\" placeholder=\"Address\/City\/State\" aria-errormessage=\"wpforms-42102-field_82-error\" ><\/div><div id=\"wpforms-42102-field_83-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_83\">Have you had any operations?<\/label><input type=\"text\" id=\"wpforms-42102-field_83\" class=\"wpforms-field-large\" name=\"wpforms[fields][83]\" aria-errormessage=\"wpforms-42102-field_83-error\" ><\/div><div id=\"wpforms-42102-field_84-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_84\">Have you ever been hospitalized for reasons other than operations?<\/label><input type=\"text\" id=\"wpforms-42102-field_84\" class=\"wpforms-field-large\" name=\"wpforms[fields][84]\" aria-errormessage=\"wpforms-42102-field_84-error\" ><\/div><div id=\"wpforms-42102-field_85-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_85\">Please list all medicines you take now and specify doses:<\/label><input type=\"text\" id=\"wpforms-42102-field_85\" class=\"wpforms-field-large\" name=\"wpforms[fields][85]\" placeholder=\" include over-the-counter medicines and supplements\" aria-errormessage=\"wpforms-42102-field_85-error\" ><\/div><div id=\"wpforms-42102-field_86-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_86\">Please list any allergies or reactions<\/label><input type=\"text\" id=\"wpforms-42102-field_86\" class=\"wpforms-field-large\" name=\"wpforms[fields][86]\" aria-errormessage=\"wpforms-42102-field_86-error\" ><\/div><div id=\"wpforms-42102-field_94-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"94\"><fieldset><legend class=\"wpforms-field-label\">Blood transfusion<\/legend><ul id=\"wpforms-42102-field_94\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_94_1\" name=\"wpforms[fields][94]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_94_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_94_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_94_2\" name=\"wpforms[fields][94]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_94_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_94_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_95-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Anemia<\/legend><ul id=\"wpforms-42102-field_95\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_95_1\" name=\"wpforms[fields][95]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_95_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_95_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_95_2\" name=\"wpforms[fields][95]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_95_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_95_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_96-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">Asthma\/Emphysema:<\/legend><ul id=\"wpforms-42102-field_96\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_96_1\" name=\"wpforms[fields][96]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_96_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_96_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_96_2\" name=\"wpforms[fields][96]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_96_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_96_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_97-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Arthritis:<\/legend><ul id=\"wpforms-42102-field_97\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_97_1\" name=\"wpforms[fields][97]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_97_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_97_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_97_2\" name=\"wpforms[fields][97]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_97_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_97_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_98-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Bladder or Kidney Infections<\/legend><ul id=\"wpforms-42102-field_98\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_98_1\" name=\"wpforms[fields][98]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_98_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_98_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_98_2\" name=\"wpforms[fields][98]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_98_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_98_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_99-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"99\"><fieldset><legend class=\"wpforms-field-label\">Blood Clots\/Bleeding disorders<\/legend><ul id=\"wpforms-42102-field_99\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_99_1\" name=\"wpforms[fields][99]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_99_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_99_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_99_2\" name=\"wpforms[fields][99]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_99_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_99_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_100-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">Chronic Diarrhea<\/legend><ul id=\"wpforms-42102-field_100\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_100_1\" name=\"wpforms[fields][100]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_100_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_100_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_100_2\" name=\"wpforms[fields][100]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_100_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_100_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_101-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">Diverticulosis<\/legend><ul id=\"wpforms-42102-field_101\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_101_1\" name=\"wpforms[fields][101]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_101_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_101_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_101_2\" name=\"wpforms[fields][101]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_101_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_101_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_102-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"102\"><fieldset><legend class=\"wpforms-field-label\">Diabetes<\/legend><ul id=\"wpforms-42102-field_102\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_102_1\" name=\"wpforms[fields][102]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_102_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_102_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_102_2\" name=\"wpforms[fields][102]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_102_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_102_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_103-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"103\"><fieldset><legend class=\"wpforms-field-label\">Epilepsy or Seizures<\/legend><ul id=\"wpforms-42102-field_103\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_103_1\" name=\"wpforms[fields][103]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_103_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_103_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_103_2\" name=\"wpforms[fields][103]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_103_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_103_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_104-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"104\"><fieldset><legend class=\"wpforms-field-label\">Gallstones\/Gallbladder Disease<\/legend><ul id=\"wpforms-42102-field_104\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_104_1\" name=\"wpforms[fields][104]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_104_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_104_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_104_2\" name=\"wpforms[fields][104]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_104_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_104_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_105-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"105\"><fieldset><legend class=\"wpforms-field-label\">Gout<\/legend><ul id=\"wpforms-42102-field_105\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_105_1\" name=\"wpforms[fields][105]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_105_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_105_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_105_2\" name=\"wpforms[fields][105]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_105_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_105_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_106-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label\">Heart Disease<\/legend><ul id=\"wpforms-42102-field_106\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_106_1\" name=\"wpforms[fields][106]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_106_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_106_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_106_2\" name=\"wpforms[fields][106]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_106_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_106_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_107-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">Cholesterol<\/legend><ul id=\"wpforms-42102-field_107\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_107_1\" name=\"wpforms[fields][107]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_107_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_107_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_107_2\" name=\"wpforms[fields][107]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_107_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_107_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_108-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"108\"><fieldset><legend class=\"wpforms-field-label\">High Blood Pressure<\/legend><ul id=\"wpforms-42102-field_108\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_108_1\" name=\"wpforms[fields][108]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_108_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_108_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_108_2\" name=\"wpforms[fields][108]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_108_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_108_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_109-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"109\"><fieldset><legend class=\"wpforms-field-label\">Kidney Disease\/Stones<\/legend><ul id=\"wpforms-42102-field_109\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_109_1\" name=\"wpforms[fields][109]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_109_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_109_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_109_2\" name=\"wpforms[fields][109]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_109_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_109_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_110-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"110\"><fieldset><legend class=\"wpforms-field-label\">Liver Disease\/Hepatitis<\/legend><ul id=\"wpforms-42102-field_110\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_110_1\" name=\"wpforms[fields][110]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_110_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_110_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_110_2\" name=\"wpforms[fields][110]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_110_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_110_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_111-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"111\"><fieldset><legend class=\"wpforms-field-label\">Lung Disease\/Pneumonia<\/legend><ul id=\"wpforms-42102-field_111\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_111_1\" name=\"wpforms[fields][111]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_111_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_111_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_111_2\" name=\"wpforms[fields][111]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_111_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_111_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_112-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"112\"><fieldset><legend class=\"wpforms-field-label\">Polyps<\/legend><ul id=\"wpforms-42102-field_112\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_112_1\" name=\"wpforms[fields][112]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_112_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_112_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_112_2\" name=\"wpforms[fields][112]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_112_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_112_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_113-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"113\"><fieldset><legend class=\"wpforms-field-label\">Rheumatic Fever<\/legend><ul id=\"wpforms-42102-field_113\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_113_1\" name=\"wpforms[fields][113]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_113_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_113_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_113_2\" name=\"wpforms[fields][113]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_113_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_113_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_114-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"114\"><fieldset><legend class=\"wpforms-field-label\">Sleep apnea<\/legend><ul id=\"wpforms-42102-field_114\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_114_1\" name=\"wpforms[fields][114]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_114_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_114_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_114_2\" name=\"wpforms[fields][114]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_114_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_114_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_115-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"115\"><fieldset><legend class=\"wpforms-field-label\">Stroke<\/legend><ul id=\"wpforms-42102-field_115\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_115_1\" name=\"wpforms[fields][115]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_115_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_115_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_115_2\" name=\"wpforms[fields][115]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_115_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_115_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_116-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"116\"><fieldset><legend class=\"wpforms-field-label\">Thyroid Disease\/Goiter<\/legend><ul id=\"wpforms-42102-field_116\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_116_1\" name=\"wpforms[fields][116]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_116_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_116_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_116_2\" name=\"wpforms[fields][116]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_116_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_116_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_117-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"117\"><fieldset><legend class=\"wpforms-field-label\">Ulcers (stomach or intestinal)<\/legend><ul id=\"wpforms-42102-field_117\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_117_1\" name=\"wpforms[fields][117]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_117_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_117_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_117_2\" name=\"wpforms[fields][117]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_117_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_117_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_118-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"118\"><fieldset><legend class=\"wpforms-field-label\">Reflux<\/legend><ul id=\"wpforms-42102-field_118\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_118_1\" name=\"wpforms[fields][118]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_118_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_118_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_118_2\" name=\"wpforms[fields][118]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_118_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_118_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_119-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"119\"><fieldset><legend class=\"wpforms-field-label\">Sexually-transmitted disease<\/legend><ul id=\"wpforms-42102-field_119\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_119_1\" name=\"wpforms[fields][119]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_119_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_119_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_119_2\" name=\"wpforms[fields][119]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_119_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_119_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_120-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"120\"><fieldset><legend class=\"wpforms-field-label\">Smoking<\/legend><ul id=\"wpforms-42102-field_120\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_120_1\" name=\"wpforms[fields][120]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_120_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_120_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_120_2\" name=\"wpforms[fields][120]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_120_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_120_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_121-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-fourth\" data-field-id=\"121\"><fieldset><legend class=\"wpforms-field-label\">Alcohol<\/legend><ul id=\"wpforms-42102-field_121\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42102-field_121_1\" name=\"wpforms[fields][121]\" value=\"No\" aria-errormessage=\"wpforms-42102-field_121_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_121_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42102-field_121_2\" name=\"wpforms[fields][121]\" value=\"Yes\" aria-errormessage=\"wpforms-42102-field_121_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_121_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_126-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_126\">Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills?<\/label><input type=\"text\" id=\"wpforms-42102-field_126\" class=\"wpforms-field-large\" name=\"wpforms[fields][126]\" aria-errormessage=\"wpforms-42102-field_126-error\" ><\/div><div id=\"wpforms-42102-field_128-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"128\"><label class=\"wpforms-field-label\" for=\"wpforms-42102-field_128\">Message<\/label><textarea id=\"wpforms-42102-field_128\" class=\"wpforms-field-large\" name=\"wpforms[fields][128]\" placeholder=\"Message\" aria-errormessage=\"wpforms-42102-field_128-error\" ><\/textarea><\/div><div id=\"wpforms-42102-field_34-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"34\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Acceptence <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-42102-field_34\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-42102-field_34_1\" name=\"wpforms[fields][34][]\" value=\"By clicking Submit, you agree to our &lt;a href=&quot;https:\/\/clinicmono.com\/terms-condition\/&quot;&gt;&lt;strong&gt;Terms and Conditions&lt;\/strong&gt;&lt;\/a&gt;\" aria-errormessage=\"wpforms-42102-field_34_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_34_1\">By clicking Submit, you agree to our <a href=\"https:\/\/clinicmono.com\/terms-condition\/\"><strong>Terms and Conditions<\/strong><\/a><\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_133-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"133\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Acceptence (copy) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-42102-field_133\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-42102-field_133_1\" name=\"wpforms[fields][133][]\" value=\"I have read, understood and approved the general terms and conditions, &lt;a target=&quot;_blank&quot; href=&quot;https:\/\/clinicmono.com\/clarification-text-for-health-check-form\/&quot;&gt;the clarification text&lt;\/a&gt;, &lt;a target=&quot;_blank&quot; href=&quot;https:\/\/clinicmono.com\/explict-consent-form-for-health-check-form\/&quot;&gt;the explicit consent text&lt;\/a&gt;.\" aria-errormessage=\"wpforms-42102-field_133_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42102-field_133_1\">I have read, understood and approved the general terms and conditions, <a target=\"_blank\" href=\"https:\/\/clinicmono.com\/clarification-text-for-health-check-form\/\">the clarification text<\/a>, <a target=\"_blank\" href=\"https:\/\/clinicmono.com\/explict-consent-form-for-health-check-form\/\">the explicit consent text<\/a>.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42102-field_130-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"130\"><input type=\"hidden\" id=\"wpforms-42102-field_130\" name=\"wpforms[fields][130]\"><\/div><div id=\"wpforms-42102-field_129-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"129\"><input type=\"hidden\" id=\"wpforms-42102-field_129\" name=\"wpforms[fields][129]\" value=\"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985 \"><\/div><div id=\"wpforms-42102-field_131-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"131\"><input type=\"hidden\" id=\"wpforms-42102-field_131\" name=\"wpforms[fields][131]\" value=\" 216.73.216.38 {entry_geolocation}\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-42102-field-hp\" class=\"wpforms-field-label\">Website<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-42102-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"42102\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-42102\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div><\/div><\/div><\/div><div class=\"g-cols wpb_row hide_on_default hide_on_laptops via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpforms-container wpforms-render-modern\" id=\"wpforms-42096\"><form id=\"wpforms-form-42096\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"42096\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/135985\" data-token=\"0802f4238d40d9ea266b980284a647f9\" data-token-time=\"1775993802\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-42096-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_1\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-42096-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"Name\" aria-errormessage=\"wpforms-42096-field_1-error\" required><\/div><div id=\"wpforms-42096-field_70-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_70\">Surname <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-42096-field_70\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][70]\" placeholder=\"Surname\" aria-errormessage=\"wpforms-42096-field_70-error\" required><\/div><div id=\"wpforms-42096-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_4\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-42096-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" placeholder=\"Email\" spellcheck=\"false\" aria-errormessage=\"wpforms-42096-field_4-error\" required><\/div><div id=\"wpforms-42096-field_132-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"132\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_132\">Birthday<\/label><input type=\"text\" id=\"wpforms-42096-field_132\" class=\"wpforms-field-large\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-42096-field_132-error\" ><\/div><div id=\"wpforms-42096-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_75\">Occupation<\/label><input type=\"text\" id=\"wpforms-42096-field_75\" class=\"wpforms-field-large\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-42096-field_75-error\" ><\/div><div id=\"wpforms-42096-field_76-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_76\">Height<\/label><input type=\"text\" id=\"wpforms-42096-field_76\" class=\"wpforms-field-large\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-42096-field_76-error\" ><\/div><div id=\"wpforms-42096-field_77-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_77\">Weight<\/label><input type=\"text\" id=\"wpforms-42096-field_77\" class=\"wpforms-field-large\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-42096-field_77-error\" ><\/div><div id=\"wpforms-42096-field_78-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_78\">BMI Index<\/label><input type=\"text\" id=\"wpforms-42096-field_78\" class=\"wpforms-field-large\" name=\"wpforms[fields][78]\" aria-errormessage=\"wpforms-42096-field_78-error\" ><\/div><div id=\"wpforms-42096-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_79\">Country<\/label><input type=\"text\" id=\"wpforms-42096-field_79\" class=\"wpforms-field-large\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-42096-field_79-error\" ><\/div><div id=\"wpforms-42096-field_3-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_3\">Phone Number <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-42096-field_3\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][3]\" placeholder=\"Phone Number\" aria-label=\"Phone Number\" aria-errormessage=\"wpforms-42096-field_3-error\" required><\/div><div id=\"wpforms-42096-field_82-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_82\">Address<\/label><input type=\"text\" id=\"wpforms-42096-field_82\" class=\"wpforms-field-large\" name=\"wpforms[fields][82]\" placeholder=\"Address\/City\/State\" aria-errormessage=\"wpforms-42096-field_82-error\" ><\/div><div id=\"wpforms-42096-field_83-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_83\">Have you had any operations?<\/label><input type=\"text\" id=\"wpforms-42096-field_83\" class=\"wpforms-field-large\" name=\"wpforms[fields][83]\" aria-errormessage=\"wpforms-42096-field_83-error\" ><\/div><div id=\"wpforms-42096-field_84-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_84\">Have you ever been hospitalized for reasons other than operations?<\/label><input type=\"text\" id=\"wpforms-42096-field_84\" class=\"wpforms-field-large\" name=\"wpforms[fields][84]\" aria-errormessage=\"wpforms-42096-field_84-error\" ><\/div><div id=\"wpforms-42096-field_85-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_85\">Please list all medicines you take now and specify doses:<\/label><input type=\"text\" id=\"wpforms-42096-field_85\" class=\"wpforms-field-large\" name=\"wpforms[fields][85]\" placeholder=\" include over-the-counter medicines and supplements\" aria-errormessage=\"wpforms-42096-field_85-error\" ><\/div><div id=\"wpforms-42096-field_86-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_86\">Please list any allergies or reactions<\/label><input type=\"text\" id=\"wpforms-42096-field_86\" class=\"wpforms-field-large\" name=\"wpforms[fields][86]\" aria-errormessage=\"wpforms-42096-field_86-error\" ><\/div><div id=\"wpforms-42096-field_94-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"94\"><fieldset><legend class=\"wpforms-field-label\">Blood transfusion<\/legend><ul id=\"wpforms-42096-field_94\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_94_1\" name=\"wpforms[fields][94]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_94_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_94_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_94_2\" name=\"wpforms[fields][94]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_94_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_94_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_95-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Anemia<\/legend><ul id=\"wpforms-42096-field_95\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_95_1\" name=\"wpforms[fields][95]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_95_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_95_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_95_2\" name=\"wpforms[fields][95]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_95_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_95_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_96-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">Asthma\/Emphysema:<\/legend><ul id=\"wpforms-42096-field_96\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_96_1\" name=\"wpforms[fields][96]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_96_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_96_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_96_2\" name=\"wpforms[fields][96]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_96_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_96_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_97-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Arthritis:<\/legend><ul id=\"wpforms-42096-field_97\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_97_1\" name=\"wpforms[fields][97]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_97_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_97_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_97_2\" name=\"wpforms[fields][97]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_97_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_97_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_98-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"98\"><fieldset><legend class=\"wpforms-field-label\">Bladder or Kidney Infections<\/legend><ul id=\"wpforms-42096-field_98\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_98_1\" name=\"wpforms[fields][98]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_98_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_98_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_98_2\" name=\"wpforms[fields][98]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_98_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_98_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_99-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"99\"><fieldset><legend class=\"wpforms-field-label\">Blood Clots\/Bleeding disorders<\/legend><ul id=\"wpforms-42096-field_99\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_99_1\" name=\"wpforms[fields][99]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_99_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_99_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_99_2\" name=\"wpforms[fields][99]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_99_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_99_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_100-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">Chronic Diarrhea<\/legend><ul id=\"wpforms-42096-field_100\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_100_1\" name=\"wpforms[fields][100]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_100_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_100_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_100_2\" name=\"wpforms[fields][100]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_100_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_100_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_101-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"101\"><fieldset><legend class=\"wpforms-field-label\">Diverticulosis<\/legend><ul id=\"wpforms-42096-field_101\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_101_1\" name=\"wpforms[fields][101]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_101_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_101_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_101_2\" name=\"wpforms[fields][101]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_101_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_101_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_102-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"102\"><fieldset><legend class=\"wpforms-field-label\">Diabetes<\/legend><ul id=\"wpforms-42096-field_102\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_102_1\" name=\"wpforms[fields][102]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_102_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_102_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_102_2\" name=\"wpforms[fields][102]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_102_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_102_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_103-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"103\"><fieldset><legend class=\"wpforms-field-label\">Epilepsy or Seizures<\/legend><ul id=\"wpforms-42096-field_103\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_103_1\" name=\"wpforms[fields][103]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_103_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_103_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_103_2\" name=\"wpforms[fields][103]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_103_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_103_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_104-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"104\"><fieldset><legend class=\"wpforms-field-label\">Gallstones\/Gallbladder Disease<\/legend><ul id=\"wpforms-42096-field_104\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_104_1\" name=\"wpforms[fields][104]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_104_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_104_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_104_2\" name=\"wpforms[fields][104]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_104_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_104_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_105-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"105\"><fieldset><legend class=\"wpforms-field-label\">Gout<\/legend><ul id=\"wpforms-42096-field_105\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_105_1\" name=\"wpforms[fields][105]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_105_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_105_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_105_2\" name=\"wpforms[fields][105]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_105_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_105_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_106-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"106\"><fieldset><legend class=\"wpforms-field-label\">Heart Disease<\/legend><ul id=\"wpforms-42096-field_106\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_106_1\" name=\"wpforms[fields][106]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_106_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_106_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_106_2\" name=\"wpforms[fields][106]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_106_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_106_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_107-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"107\"><fieldset><legend class=\"wpforms-field-label\">Cholesterol<\/legend><ul id=\"wpforms-42096-field_107\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_107_1\" name=\"wpforms[fields][107]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_107_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_107_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_107_2\" name=\"wpforms[fields][107]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_107_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_107_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_108-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"108\"><fieldset><legend class=\"wpforms-field-label\">High Blood Pressure<\/legend><ul id=\"wpforms-42096-field_108\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_108_1\" name=\"wpforms[fields][108]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_108_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_108_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_108_2\" name=\"wpforms[fields][108]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_108_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_108_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_109-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"109\"><fieldset><legend class=\"wpforms-field-label\">Kidney Disease\/Stones<\/legend><ul id=\"wpforms-42096-field_109\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_109_1\" name=\"wpforms[fields][109]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_109_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_109_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_109_2\" name=\"wpforms[fields][109]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_109_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_109_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_110-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"110\"><fieldset><legend class=\"wpforms-field-label\">Liver Disease\/Hepatitis<\/legend><ul id=\"wpforms-42096-field_110\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_110_1\" name=\"wpforms[fields][110]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_110_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_110_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_110_2\" name=\"wpforms[fields][110]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_110_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_110_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_111-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"111\"><fieldset><legend class=\"wpforms-field-label\">Lung Disease\/Pneumonia<\/legend><ul id=\"wpforms-42096-field_111\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_111_1\" name=\"wpforms[fields][111]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_111_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_111_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_111_2\" name=\"wpforms[fields][111]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_111_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_111_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_112-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"112\"><fieldset><legend class=\"wpforms-field-label\">Polyps<\/legend><ul id=\"wpforms-42096-field_112\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_112_1\" name=\"wpforms[fields][112]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_112_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_112_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_112_2\" name=\"wpforms[fields][112]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_112_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_112_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_113-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"113\"><fieldset><legend class=\"wpforms-field-label\">Rheumatic Fever<\/legend><ul id=\"wpforms-42096-field_113\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_113_1\" name=\"wpforms[fields][113]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_113_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_113_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_113_2\" name=\"wpforms[fields][113]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_113_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_113_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_114-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"114\"><fieldset><legend class=\"wpforms-field-label\">Sleep apnea<\/legend><ul id=\"wpforms-42096-field_114\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_114_1\" name=\"wpforms[fields][114]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_114_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_114_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_114_2\" name=\"wpforms[fields][114]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_114_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_114_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_115-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"115\"><fieldset><legend class=\"wpforms-field-label\">Stroke<\/legend><ul id=\"wpforms-42096-field_115\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_115_1\" name=\"wpforms[fields][115]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_115_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_115_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_115_2\" name=\"wpforms[fields][115]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_115_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_115_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_116-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"116\"><fieldset><legend class=\"wpforms-field-label\">Thyroid Disease\/Goiter<\/legend><ul id=\"wpforms-42096-field_116\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_116_1\" name=\"wpforms[fields][116]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_116_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_116_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_116_2\" name=\"wpforms[fields][116]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_116_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_116_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_117-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"117\"><fieldset><legend class=\"wpforms-field-label\">Ulcers (stomach or intestinal)<\/legend><ul id=\"wpforms-42096-field_117\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_117_1\" name=\"wpforms[fields][117]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_117_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_117_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_117_2\" name=\"wpforms[fields][117]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_117_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_117_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_118-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"118\"><fieldset><legend class=\"wpforms-field-label\">Reflux<\/legend><ul id=\"wpforms-42096-field_118\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_118_1\" name=\"wpforms[fields][118]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_118_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_118_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_118_2\" name=\"wpforms[fields][118]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_118_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_118_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_119-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"119\"><fieldset><legend class=\"wpforms-field-label\">Sexually-transmitted disease<\/legend><ul id=\"wpforms-42096-field_119\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_119_1\" name=\"wpforms[fields][119]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_119_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_119_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_119_2\" name=\"wpforms[fields][119]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_119_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_119_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_120-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"120\"><fieldset><legend class=\"wpforms-field-label\">Smoking<\/legend><ul id=\"wpforms-42096-field_120\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_120_1\" name=\"wpforms[fields][120]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_120_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_120_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_120_2\" name=\"wpforms[fields][120]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_120_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_120_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_121-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"121\"><fieldset><legend class=\"wpforms-field-label\">Alcohol<\/legend><ul id=\"wpforms-42096-field_121\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-42096-field_121_1\" name=\"wpforms[fields][121]\" value=\"No\" aria-errormessage=\"wpforms-42096-field_121_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_121_1\">No<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-42096-field_121_2\" name=\"wpforms[fields][121]\" value=\"Yes\" aria-errormessage=\"wpforms-42096-field_121_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_121_2\">Yes<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_126-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-42096-field_126\">Have you ever used any drugs such as marijuana, cocaine, stimulants, sedatives, narcotics, diet pills?<\/label><input type=\"text\" id=\"wpforms-42096-field_126\" class=\"wpforms-field-large\" 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id=\"wpforms-42096-field_131-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"131\"><input type=\"hidden\" id=\"wpforms-42096-field_131\" name=\"wpforms[fields][131]\" value=\" 216.73.216.38 {entry_geolocation}\"><\/div><div id=\"wpforms-42096-field_34-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"34\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Acceptence <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-42096-field_34\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-42096-field_34_1\" name=\"wpforms[fields][34][]\" value=\"By clicking Submit, you agree to our &lt;a href=&quot;https:\/\/clinicmono.com\/terms-condition\/&quot;&gt;&lt;strong&gt;Terms and Conditions&lt;\/strong&gt;&lt;\/a&gt;\" aria-errormessage=\"wpforms-42096-field_34_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_34_1\">By clicking Submit, you agree to our <a href=\"https:\/\/clinicmono.com\/terms-condition\/\"><strong>Terms and Conditions<\/strong><\/a><\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-42096-field_133-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"133\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Acceptence (copy) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-42096-field_133\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-42096-field_133_1\" name=\"wpforms[fields][133][]\" value=\"I have read, understood and approved the general terms and conditions, &lt;a target=&quot;_blank&quot; href=&quot;https:\/\/clinicmono.com\/clarification-text-for-health-check-form\/&quot;&gt;the clarification text&lt;\/a&gt;, &lt;a target=&quot;_blank&quot; href=&quot;https:\/\/clinicmono.com\/explict-consent-form-for-health-check-form\/&quot;&gt;the explicit consent text&lt;\/a&gt;.\" aria-errormessage=\"wpforms-42096-field_133_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-42096-field_133_1\">I have read, understood and approved the general terms and conditions, <a target=\"_blank\" href=\"https:\/\/clinicmono.com\/clarification-text-for-health-check-form\/\">the clarification text<\/a>, <a target=\"_blank\" href=\"https:\/\/clinicmono.com\/explict-consent-form-for-health-check-form\/\">the explicit consent text<\/a>.<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"42096\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-42096\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/clinicmono.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Chargement en cours\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n","protected":false},"excerpt":{"rendered":"Formulaire de bilan de sant\u00e9 Ob\u00e9sit\u00e9 Clinique MonoPagesVeuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.Name *Surname *Email *Birthday *OccupationHeightWeightBMI IndexCountryPhone Number *AddressHave you had any operations?Have you ever been hospitalized for reasons other than operations?Please list all medicines you take now and specify doses:Please...","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"rank_math_lock_modified_date":false,"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_uf_show_specific_survey":0,"_uf_disable_surveys":false,"footnotes":""},"procedure":[],"class_list":["post-135985","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985"}],"collection":[{"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/comments?post=135985"}],"version-history":[{"count":1,"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985\/revisions"}],"predecessor-version":[{"id":135989,"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/pages\/135985\/revisions\/135989"}],"wp:attachment":[{"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/media?parent=135985"}],"wp:term":[{"taxonomy":"procedure","embeddable":true,"href":"https:\/\/clinicmono.com\/fr\/wp-json\/wp\/v2\/procedure?post=135985"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}