{"id":357,"date":"2018-02-06T19:32:06","date_gmt":"2018-02-07T00:32:06","guid":{"rendered":"http:\/\/box5582.temp.domains\/~bestcoa9\/?page_id=357"},"modified":"2024-02-11T21:57:19","modified_gmt":"2024-02-12T02:57:19","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/bestcoastinternalmedicine.com\/new-patient-form\/","title":{"rendered":"New Patient Form"},"content":{"rendered":"\n\n\t\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1308-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/357#wpcf7-f1308-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1308\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1308-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:1308,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;history-cancer&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;history_cancer&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Cancer&quot;}]},{&quot;then_field&quot;:&quot;history-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;history_other&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;surgery-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;sh_Other&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;smoker-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;smoker&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Never&quot;}]},{&quot;then_field&quot;:&quot;birth-control&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;birth_control&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;std&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;had_std&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;drugs&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;use_drugs&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Never&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;notice_dismissed_update-cf7-5.5.4&quot;:true}}\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"https:\/\/bestcoastinternalmedicine.com\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/bestcoastinternalmedicine.com\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.1.10\"><\/script><!-- Patient Info -->\n<h2>Patient Information\n<\/h2>\n<fieldset>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Choose Your Doctor<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"doctor\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Jorge L. Hernandez, M.D.\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Dr. Jorge L. Hernandez, M.D.<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Waguih El Masry, M.D.\" \/><span class=\"wpcf7-list-item-label\">Dr. Waguih El Masry, M.D.<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Sean Nonnemaker, D.O.\" \/><span class=\"wpcf7-list-item-label\">Dr. Sean Nonnemaker, D.O.<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Leslie Gomez, D.O.\" \/><span class=\"wpcf7-list-item-label\">Dr. Leslie Gomez, D.O.<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Lisa Shannon, D.O.\" \/><span class=\"wpcf7-list-item-label\">Dr. Lisa Shannon, D.O.<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"doctor\" value=\"Dr. Juliana Dale, DO\" \/><span class=\"wpcf7-list-item-label\">Dr. Juliana Dale, DO<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"Primary_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Primary_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>DOB:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"Primary_DOB\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Primary_DOB\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Reason for Visit:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"Primary_Reason_for_Visit\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Primary_Reason_for_Visit\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Preferred Pharmacy:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"Primary_Preferred_Pharmacy\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Primary_Preferred_Pharmacy\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Do you have any allergies?<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"Primary_Allergies\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Primary_Allergies\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Medications -->\n<h2>Medications\n<\/h2>\n<fieldset>\n\t<p>List of medications CURRENTLY being taken (prescribed, over the counter, and vitamins)\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_1_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_1_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_1_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_1_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_1_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_1_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_2_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_2_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_2_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_2_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_2_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_2_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_3_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_3_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_3_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_3_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_3_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_3_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_4_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_4_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_4_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_4_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_4_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_4_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_5_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_5_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_5_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_5_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_5_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_5_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_6_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_6_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_6_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_6_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_6_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_6_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_7_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_7_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_7_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_7_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_7_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_7_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_8_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_8_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_8_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_8_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_8_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_8_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_9_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_9_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_9_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_9_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_9_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_9_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_10_Name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_10_Name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Strength: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_10_Strength\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_10_Strength\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How Often: <span class=\"wpcf7-form-control-wrap\" data-name=\"Medications_10_Frequency\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Medications_10_Frequency\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Medical History -->\n<h2>Medical History\n<\/h2>\n<fieldset>\n\t<p>Mark ALL that apply.\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history_add\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_add[]\" value=\"ADD\" \/><span class=\"wpcf7-list-item-label\">ADD<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_adhd\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_adhd[]\" value=\"ADHD\" \/><span class=\"wpcf7-list-item-label\">ADHD<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_anemia\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_anemia[]\" value=\"Anemia\" \/><span class=\"wpcf7-list-item-label\">Anemia<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_angina\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_angina[]\" value=\"Angina\" \/><span class=\"wpcf7-list-item-label\">Angina<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_anxiety\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_anxiety[]\" value=\"Anxiety\" \/><span class=\"wpcf7-list-item-label\">Anxiety<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_arthritis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_arthritis[]\" value=\"Arthritis\" \/><span class=\"wpcf7-list-item-label\">Arthritis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_asthma\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_asthma[]\" value=\"Asthma\" \/><span class=\"wpcf7-list-item-label\">Asthma<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_atrial_fibrillation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_atrial_fibrillation[]\" value=\"Atrial Fibrillation\" \/><span class=\"wpcf7-list-item-label\">Atrial Fibrillation<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_bipolar_disorder\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_bipolar_disorder[]\" value=\"Bipolar Disorder\" \/><span class=\"wpcf7-list-item-label\">Bipolar Disorder<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_bladder_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_bladder_cancer[]\" value=\"Bladder Cancer\" \/><span class=\"wpcf7-list-item-label\">Bladder Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_bowel_problems\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_bowel_problems[]\" value=\"Bowel Problems\" \/><span class=\"wpcf7-list-item-label\">Bowel Problems<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_breast_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_breast_cancer[]\" value=\"Breast Cancer\" \/><span class=\"wpcf7-list-item-label\">Breast Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_breathing_difficulties\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_breathing_difficulties[]\" value=\"Breathing Difficulties\" \/><span class=\"wpcf7-list-item-label\">Breathing Difficulties<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_cancer[]\" value=\"Cancer\" \/><span class=\"wpcf7-list-item-label\">Cancer<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div data-id=\"history-cancer\" data-orig_data_id=\"history-cancer\"  data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"history_cancer_type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history_cancer_type\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history_cirrhosis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_cirrhosis[]\" value=\"Cirrhosis\" \/><span class=\"wpcf7-list-item-label\">Cirrhosis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_colon_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_colon_cancer[]\" value=\"Colon Cancer\" \/><span class=\"wpcf7-list-item-label\">Colon Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_copd\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_copd[]\" value=\"COPD\" \/><span class=\"wpcf7-list-item-label\">COPD<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_chrons\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_chrons[]\" value=\"Crohn&#039;s Disease\" \/><span class=\"wpcf7-list-item-label\">Crohn&#039;s Disease<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history_dementia\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_dementia[]\" value=\"Dementia\" \/><span class=\"wpcf7-list-item-label\">Dementia<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_depresion\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_depresion[]\" value=\"Depression\" \/><span class=\"wpcf7-list-item-label\">Depression<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_diabetes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_diabetes[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_diverticulitis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_diverticulitis[]\" value=\"Diverticulitis\" \/><span class=\"wpcf7-list-item-label\">Diverticulitis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_eczema\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_eczema[]\" value=\"Eczema\" \/><span class=\"wpcf7-list-item-label\">Eczema<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_emphysema\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_emphysema[]\" value=\"Emphysema\" \/><span class=\"wpcf7-list-item-label\">Emphysema<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_gerd\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_gerd[]\" value=\"GERD\" \/><span class=\"wpcf7-list-item-label\">GERD<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_gout\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_gout[]\" value=\"Gout\" \/><span class=\"wpcf7-list-item-label\">Gout<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_heart_attack\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_heart_attack[]\" value=\"Heart Attack\" \/><span class=\"wpcf7-list-item-label\">Heart Attack<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_heart_disease\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_heart_disease[]\" value=\"Heart Disease\" \/><span class=\"wpcf7-list-item-label\">Heart Disease<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_heart_murmur\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_heart_murmur[]\" value=\"Heart Murmur\" \/><span class=\"wpcf7-list-item-label\">Heart Murmur<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_hepatitis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_hepatitis[]\" value=\"Hepatitis (A, B, or C)\" \/><span class=\"wpcf7-list-item-label\">Hepatitis (A, B, or C)<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_high_bp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_high_bp[]\" value=\"High Blood Pressure\" \/><span class=\"wpcf7-list-item-label\">High Blood Pressure<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_high_cholesterol\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_high_cholesterol[]\" value=\"High Cholesterol\" \/><span class=\"wpcf7-list-item-label\">High Cholesterol<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_liver_proplems\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_liver_proplems[]\" value=\"Liver Problems\" \/><span class=\"wpcf7-list-item-label\">Liver Problems<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_lung_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_lung_cancer[]\" value=\"Lung Cancer\" \/><span class=\"wpcf7-list-item-label\">Lung Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_migraines\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_migraines[]\" value=\"Migraines\" \/><span class=\"wpcf7-list-item-label\">Migraines<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history_osteoarthritis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_osteoarthritis[]\" value=\"Osteoarthritis\" \/><span class=\"wpcf7-list-item-label\">Osteoarthritis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_pancreatic_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_pancreatic_cancer[]\" value=\"Pancreatic Cancer\" \/><span class=\"wpcf7-list-item-label\">Pancreatic Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_parkinsons\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_parkinsons[]\" value=\"Parkinson\u2019s\" \/><span class=\"wpcf7-list-item-label\">Parkinson\u2019s<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_pneumonia\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_pneumonia[]\" value=\"Pneumonia\" \/><span class=\"wpcf7-list-item-label\">Pneumonia<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_polymyalgia\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_polymyalgia[]\" value=\"Polymyalgia\" \/><span class=\"wpcf7-list-item-label\">Polymyalgia<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_history_prostate_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_history_prostate_cancer[]\" value=\"Prostate Cancer\" \/><span class=\"wpcf7-list-item-label\">Prostate Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_psoriasis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_psoriasis[]\" value=\"Psoriasis\" \/><span class=\"wpcf7-list-item-label\">Psoriasis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_psychiatric_problems\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_psychiatric_problems[]\" value=\"Psychiatric Problems\" \/><span class=\"wpcf7-list-item-label\">Psychiatric Problems<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_pulmonary_embolism\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_pulmonary_embolism[]\" value=\"Pulmonary Embolism\" \/><span class=\"wpcf7-list-item-label\">Pulmonary Embolism<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_rectal_cancer\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_rectal_cancer[]\" value=\"Rectal Cancer\" \/><span class=\"wpcf7-list-item-label\">Rectal Cancer<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_rheumatoid_arthritis\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_rheumatoid_arthritis[]\" value=\"Rheumatoid Arthritis\" \/><span class=\"wpcf7-list-item-label\">Rheumatoid Arthritis<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_rosacea\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_rosacea[]\" value=\"Rosacea\" \/><span class=\"wpcf7-list-item-label\">Rosacea<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_seizure_disorder\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_seizure_disorder[]\" value=\"Seizure Disorder\" \/><span class=\"wpcf7-list-item-label\">Seizure Disorder<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_sickle_cell\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_sickle_cell[]\" value=\"Sickle Cell\" \/><span class=\"wpcf7-list-item-label\">Sickle Cell<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_sjogren_syndrome\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_sjogren_syndrome[]\" value=\"Sjogren Syndrome\" \/><span class=\"wpcf7-list-item-label\">Sjogren Syndrome<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_stroke\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_stroke[]\" value=\"Stroke\/CVA\" \/><span class=\"wpcf7-list-item-label\">Stroke\/CVA<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"history_other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"history_other[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div data-id=\"history-other\" data-orig_data_id=\"history-other\"  data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"history_other_text\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history_other_text\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Surgical Procedures -->\n<h2>Surgical Procedures\n<\/h2>\n<fieldset>\n\t<p>Mark ALL that apply.\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sh_acl\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_acl[]\" value=\"ACL Surgery\/Reconstruction\" \/><span class=\"wpcf7-list-item-label\">ACL Surgery\/Reconstruction<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_adenoids\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_adenoids[]\" value=\"Adenoids Removed\" \/><span class=\"wpcf7-list-item-label\">Adenoids Removed<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_appenidx\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_appenidx[]\" value=\"Appendix Removal\" \/><span class=\"wpcf7-list-item-label\">Appendix Removal<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_back_surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_back_surgery[]\" value=\"Back Surgery\" \/><span class=\"wpcf7-list-item-label\">Back Surgery<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_gallbladder\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_gallbladder[]\" value=\"Gallbladder Removed\" \/><span class=\"wpcf7-list-item-label\">Gallbladder Removed<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_hip_replacement\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_hip_replacement[]\" value=\"Hip Replacement\" \/><span class=\"wpcf7-list-item-label\">Hip Replacement<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_knee_replacement\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_knee_replacement[]\" value=\"Knee Replacement\" \/><span class=\"wpcf7-list-item-label\">Knee Replacement<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_hysterectomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_hysterectomy[]\" value=\"Hysterectomy\" \/><span class=\"wpcf7-list-item-label\">Hysterectomy<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_splenectomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_splenectomy[]\" value=\"Splenectomy\" \/><span class=\"wpcf7-list-item-label\">Splenectomy<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_tonsils\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_tonsils[]\" value=\"Tonsils Removed\" \/><span class=\"wpcf7-list-item-label\">Tonsils Removed<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sh_BreastAugmentation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_BreastAugmentation[]\" value=\"Breast Augmentation\" \/><span class=\"wpcf7-list-item-label\">Breast Augmentation<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_CardiacBypassSurgery\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_CardiacBypassSurgery[]\" value=\"Cardiac Bypass Surgery\" \/><span class=\"wpcf7-list-item-label\">Cardiac Bypass Surgery<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_CardiacCatheterization\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_CardiacCatheterization[]\" value=\"Cardiac Catheterization\" \/><span class=\"wpcf7-list-item-label\">Cardiac Catheterization<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_CataractSurgery\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_CataractSurgery[]\" value=\"Cataract Surgery\" \/><span class=\"wpcf7-list-item-label\">Cataract Surgery<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_ColonResection\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_ColonResection[]\" value=\"Colon resection\" \/><span class=\"wpcf7-list-item-label\">Colon resection<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Lumpectomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Lumpectomy[]\" value=\"Lumpectomy\" \/><span class=\"wpcf7-list-item-label\">Lumpectomy<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_LymphNodeBiopsy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_LymphNodeBiopsy[]\" value=\"Lymph Node Biopsy\" \/><span class=\"wpcf7-list-item-label\">Lymph Node Biopsy<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Mastectomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Mastectomy[]\" value=\"Mastectomy\" \/><span class=\"wpcf7-list-item-label\">Mastectomy<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_TubalLigation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_TubalLigation[]\" value=\"Tubal Ligation\" \/><span class=\"wpcf7-list-item-label\">Tubal Ligation<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Vasectomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Vasectomy[]\" value=\"Vasectomy\" \/><span class=\"wpcf7-list-item-label\">Vasectomy<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sh_TotalJointReplacement\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_TotalJointReplacement[]\" value=\"Total Joint Replacement\" \/><span class=\"wpcf7-list-item-label\">Total Joint Replacement<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Colostomy\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Colostomy[]\" value=\"Colostomy\/Reversal\" \/><span class=\"wpcf7-list-item-label\">Colostomy\/Reversal<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_CSection\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_CSection[]\" value=\"C_Section\" \/><span class=\"wpcf7-list-item-label\">C_Section<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_DC\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_DC[]\" value=\"D&amp;C (Dilation &amp; Curettage)\" \/><span class=\"wpcf7-list-item-label\">D&amp;C (Dilation &amp; Curettage)<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Defibrillator\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Defibrillator[]\" value=\"Defibrillator Implant\" \/><span class=\"wpcf7-list-item-label\">Defibrillator Implant<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Pacemaker\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Pacemaker[]\" value=\"Pacemaker\" \/><span class=\"wpcf7-list-item-label\">Pacemaker<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_PTCA\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_PTCA[]\" value=\"PTCA (Angloplasty)\" \/><span class=\"wpcf7-list-item-label\">PTCA (Angloplasty)<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_ShoulderSurgery\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_ShoulderSurgery[]\" value=\"Shoulder Surgery\" \/><span class=\"wpcf7-list-item-label\">Shoulder Surgery<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sh_Other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"sh_Other[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div data-id=\"surgery-other\" data-orig_data_id=\"surgery-other\"  data-class=\"wpcf7cf_group\">\n\t\t\t\t<p><label>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"surgery_other_text\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"surgery_other_text\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Women's Health -->\n<h2>Women's Health\n<\/h2>\n<fieldset>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Menstrual Period: <span class=\"wpcf7-form-control-wrap\" data-name=\"last_menstrual_period_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last_menstrual_period_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"menstrual_period_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"menstrual_period_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"menstrual_period_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>PAP\/Pelvic Exam: <span class=\"wpcf7-form-control-wrap\" data-name=\"pap_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pap_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pap_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pap_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pap_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Mammogram: <span class=\"wpcf7-form-control-wrap\" data-name=\"mammogram_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mammogram_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mammogram_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"mammogram_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"mammogram_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Bone Density Exam: <span class=\"wpcf7-form-control-wrap\" data-name=\"bone_density_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bone_density_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"bone_density_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"bone_density_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"bone_density_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label># of Pregnancies: <span class=\"wpcf7-form-control-wrap\" data-name=\"number_pregnancies\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number_pregnancies\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label># of Deliveries: <span class=\"wpcf7-form-control-wrap\" data-name=\"number_deliveries\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number_deliveries\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label># of Miscarriages: <span class=\"wpcf7-form-control-wrap\" data-name=\"number_miscarriages\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number_miscarriages\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label># of Abortions: <span class=\"wpcf7-form-control-wrap\" data-name=\"number_abortions\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number_abortions\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Health Maintenance -->\n<h2>Health Maintenance\n<\/h2>\n<fieldset>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Physical Exam\/Wellness Visit: <span class=\"wpcf7-form-control-wrap\" data-name=\"physical_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"physical_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"physical_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"physical_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Cholesterol: <span class=\"wpcf7-form-control-wrap\" data-name=\"cholesterol_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cholesterol_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"cholesterol_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cholesterol_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cholesterol_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Colonoscopy: <span class=\"wpcf7-form-control-wrap\" data-name=\"colonoscopy_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"colonoscopy_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"colonoscopy_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"colonoscopy_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"colonoscopy_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>EGD: <span class=\"wpcf7-form-control-wrap\" data-name=\"egd_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"egd_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"egd_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"egd_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"egd_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Prostate\/PSA: <span class=\"wpcf7-form-control-wrap\" data-name=\"prostate_exam_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"prostate_exam_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"prostate_exam_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"prostate_exam_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"prostate_exam_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Stress Test\/Nuclear Stress Test: <span class=\"wpcf7-form-control-wrap\" data-name=\"stress_test_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stress_test_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stress_test_results\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"stress_test_results[]\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"stress_test_results[]\" value=\"Abnormal\" \/><span class=\"wpcf7-list-item-label\">Abnormal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Immunizations -->\n<h2>Immunizations\n<\/h2>\n<fieldset>\n\t<p>Hepatitis A\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#1 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hep_a_1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hep_a_1\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#2 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hep_a_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hep_a_2\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Hepatitis B\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#1 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hep_b_1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hep_b_1\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#2 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hep_b_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hep_b_2\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#3 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hep_b_3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hep_b_3\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Gardasil (HPV)\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#1 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hpv_1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hpv_1\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#2 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hpv_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hpv_2\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>#3 <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_hpv_3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_hpv_3\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>COVID\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_covid_type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_covid_type\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Dates: <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_covid_dates\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_covid_dates\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Influenza <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_infleunza\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_infleunza\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Pneumonia <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_pneumonia\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_pneumonia\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Tetanus <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_tetanus\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_tetanus\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Shingrix (Shingles) <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_shingles\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_shingles\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>TB Skin Test <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_tb_skin_test\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_tb_skin_test\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Chicken Pox <span class=\"wpcf7-form-control-wrap\" data-name=\"immunization_chicken_pox\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"immunization_chicken_pox\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Social History -->\n<h2>Social History\n<\/h2>\n<fieldset>\n\t<p>Are you a smoker?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoker\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"smoker\" value=\"Never\" \/><span class=\"wpcf7-list-item-label\">Never<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"smoker\" value=\"Former\" \/><span class=\"wpcf7-list-item-label\">Former<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"smoker\" value=\"Current\" \/><span class=\"wpcf7-list-item-label\">Current<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t\n\n\t\t<!-- Conditional Group -->\n\t<div data-id=\"smoker-group\" data-orig_data_id=\"smoker-group\"  data-class=\"wpcf7cf_group\">\n\t\t<p>If YES, mark all that apply:\n\t\t<\/p>\n\t\t<div class=\"cf7-row\">\n\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_cigarettes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"smoker_cigarettes[]\" value=\"Cigarettes\" \/><span class=\"wpcf7-list-item-label\">Cigarettes<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_cigars\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"smoker_cigars[]\" value=\"Cigars\" \/><span class=\"wpcf7-list-item-label\">Cigars<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_tobacco\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"smoker_tobacco[]\" value=\"Chewing\/Dipping Tobacco\" \/><span class=\"wpcf7-list-item-label\">Chewing\/Dipping Tobacco<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_electronic_cigarettes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"smoker_electronic_cigarettes[]\" value=\"Electronic Cigarettes\" \/><span class=\"wpcf7-list-item-label\">Electronic Cigarettes<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"cf7-row\">\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>How much per day? <span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_frequeny\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"smoker_frequeny\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>How many years? <span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_duration\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"smoker_duration\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>Quit Date: <span class=\"wpcf7-form-control-wrap\" data-name=\"smoker_quit_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"smoker_quit_date\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t\t<!-- END -->\n\t<p>Do you drink alcohol?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"drinker\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"drinker\" value=\"Never\" \/><span class=\"wpcf7-list-item-label\">Never<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"drinker\" value=\"Daily\" \/><span class=\"wpcf7-list-item-label\">Daily<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"drinker\" value=\"Social\" \/><span class=\"wpcf7-list-item-label\">Social<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Estimated Daily Consumption: <span class=\"wpcf7-form-control-wrap\" data-name=\"drinker_amount\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"drinker_amount\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Are you sexually active?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"sexually_active\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"sexually_active\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"sexually_active\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Are you using a form of birth control?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth_control\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"birth_control\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"birth_control\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t\t<!-- Conditional Group -->\n\t<div data-id=\"birth-control\" data-orig_data_id=\"birth-control\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"cf7-row\">\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>If YES, what type? <span class=\"wpcf7-form-control-wrap\" data-name=\"birth_control_type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"birth_control_type\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t\t<!-- END -->\n\t<p>Have you ever had an STD?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"had_std\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"had_std[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"had_std[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t\t<!-- Conditional Group -->\n\t<div data-id=\"std\" data-orig_data_id=\"std\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"cf7-row\">\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>If YES, what type? <span class=\"wpcf7-form-control-wrap\" data-name=\"STD_type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"STD_type\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t\t<!-- END -->\n\t<p>Street Drug Use:\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"use_drugs\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"use_drugs[]\" value=\"Never\" \/><span class=\"wpcf7-list-item-label\">Never<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"use_drugs[]\" value=\"Formerly\" \/><span class=\"wpcf7-list-item-label\">Formerly<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"use_drugs[]\" value=\"Currently\" \/><span class=\"wpcf7-list-item-label\">Currently<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\n\t\t<!-- Conditional Group -->\n\t<div data-id=\"drugs\" data-orig_data_id=\"drugs\"  data-class=\"wpcf7cf_group\">\n\t\t<div class=\"cf7-row\">\n\t\t\t<div class=\"cf7-col\">\n\t\t\t\t<p><label>If YES, what type? <span class=\"wpcf7-form-control-wrap\" data-name=\"drugs_type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"drugs_type\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t\t<!-- END -->\n\t<p>Do you feel safe at home?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"safe_at_home\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"safe_at_home\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"safe_at_home\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Do you have a living will?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"living_will\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"living_will\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"living_will\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Do you have a durable Power of Attorney for healthcare?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"power_of_attorney\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"power_of_attorney\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"power_of_attorney\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Family History -->\n<h2>Family History\n<\/h2>\n<fieldset>\n\t<p>Are you adopted?\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"adopted\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"adopted[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adopted[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"adopted[]\" value=\"Unknown\" \/><span class=\"wpcf7-list-item-label\">Unknown<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Mother\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Living?\n\t\t\t<\/p>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"mother_living\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"mother_living[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"mother_living[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Age of Death: <span class=\"wpcf7-form-control-wrap\" data-name=\"mother_age_of_death\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mother_age_of_death\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Cause of Death: <span class=\"wpcf7-form-control-wrap\" data-name=\"mother_cause_of_death\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mother_cause_of_death\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Father\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Living?\n\t\t\t<\/p>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"father_living\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"father_living[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"father_living[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Age of Death: <span class=\"wpcf7-form-control-wrap\" data-name=\"father_age_of_death\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"father_age_of_death\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Cause of Death: <span class=\"wpcf7-form-control-wrap\" data-name=\"father_cause_of_death\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"father_cause_of_death\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Please list any serious medical history that runs in your family\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Mother <span class=\"wpcf7-form-control-wrap\" data-name=\"history-mother-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-mother-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Father <span class=\"wpcf7-form-control-wrap\" data-name=\"history-father-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-father-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Sibling <span class=\"wpcf7-form-control-wrap\" data-name=\"history-sibling-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-sibling-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Maternal Grandparent <span class=\"wpcf7-form-control-wrap\" data-name=\"history-m-grandparent-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-m-grandparent-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Paternal Grandparent <span class=\"wpcf7-form-control-wrap\" data-name=\"history-p-grandparent-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-p-grandparent-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-mother-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-mother-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-father-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-father-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-sibling-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-sibling-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-m-grandparent-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-m-grandparent-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-p-grandparent-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-p-grandparent-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-mother-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-mother-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-father-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-father-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-sibling-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-sibling-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-m-grandparent-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-m-grandparent-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"history-p-grandparent-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"history-p-grandparent-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Providers -->\n<h2>Other Care Providers\n<\/h2>\n<fieldset>\n\t<p>Provider List (Physician\/Practice Name)\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Cardiologist: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-cardiologist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-cardiologist\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Gastroenterologist: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-gastroenterologist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-gastroenterologist\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>General Surgeon: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-general-surgeon\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-general-surgeon\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Neurologist: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-neurologist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-neurologist\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>OBGYN: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-OBGYN\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-OBGYN\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Primary Care: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-primary-care\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-primary-care\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Urologist: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-urologist\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-urologist\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Other: <span class=\"wpcf7-form-control-wrap\" data-name=\"provider-other\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provider-other\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Hospitalizations -->\n<h2>Hospitalizations\n<\/h2>\n<fieldset>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Hospital Admission\/ER Visit? <span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Year <span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-year-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-year-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Diagnosis <span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-diagnosis-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-diagnosis-1\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-year-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-year-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-diagnosis-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-diagnosis-2\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-year-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-year-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hospital-diagnosis-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hospital-diagnosis-3\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Privacy -->\n<h2>Privacy\n<\/h2>\n<fieldset>\n\t<h4>NOTICE OF PRIVACY PRACTICES\n\t<\/h4>\n\t<p>A copy of Facility's HIPAA Notice of Privacy Practices is posted in the main lobby and available for me to read in its entirety. The HIPAA Notice of Privacy Practices contains information on the uses and disclosures of my protected health information (PHI).\n\t<\/p>\n\t<h4>DISCLOSURE OF PROTECTED HEALTH INFORMATION AND EMERGENCY CONTACT\n\t<\/h4>\n\t<p>I authorize Facility to communicate with the following individuals about my medical condition, diagnosis, treatment, appointments (past and future), and \ufb01nancial obligation. l understand medical information may be withheld from individuals, including family members unless l List them by name below.\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"disclosure_name_1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"disclosure_name_1\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"disclosure_relationship_1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"disclosure_relationship_1\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"disclosure_name_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"disclosure_name_2\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"disclosure_relationship_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"disclosure_relationship_2\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>I authorize Facility to leave voicemail or answering machine messages regarding test results or other healthcare related concerns at my home or cell phone number.\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"can_leave_voicemails_yes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"can_leave_voicemails_yes[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"can_leave_voicemails_no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"can_leave_voicemails_no[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>EMERGENCY CONTACT INFO\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Emergency Contact: <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency_contact_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency_contact_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Phone Number: <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency_contact_phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency_contact_phone\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship: <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency_contact_relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency_contact_relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Email Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency_contact_email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency_contact_email\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>FINANCIAL POLICY AND AUTHORIZATION FOR ASSIGNMENT OF BENEFITS\n\t<\/h4>\n\t<p>Facility strives to make our financial policy, Insurance filing, and billing process for our patients as simple as possible. It is your responsibility to make sure we have your correct insurance information and also your responsibility to know your co-pay, co-insurance amount, and deductible. For Self-Pay patients, payment must be made at the time of service, and a 5O% discount is offered to those patients. Patients will be assessed a $30 fee for checks returned due to Insufficient Funds. Statements are mailed out each month. Please contact our Central Billing Office for questions or concerns regarding your balance. Facility will submit claims to my primary and secondary insurance directly for their services. I authorize payment directly to Facility of any insurance benefits otherwise payable to me. Charges deemed as non-covered by insurance company are the responsibility of the patient except as required by law for State and Federal reimbursement programs. I authorize Facility to release or receive any information necessary to expedite insurance claims.\n\t<\/p>\n\t<h4>GENERAL CONSENT FOR EXAMINATION AND TREATMENT\n\t<\/h4>\n\t<p>I hereby consent and authorize Facility to perform medical examinations and provide routine medical care for all my visits. This may include routine diagnostic and laboratory procedures and tests, medication administration, and other routine care for which a specific informed consent form will not be signed by me. This consent includes consent and authorization to photograph or otherwise take images of me and\/or parts of my body for purposes of identification, diagnosis, treatment, payment, and healthcare operations of Facility. Any photographs or other images taken will become part of my medical record. Facility will not use such photographs or images for any other purposes without my specific written consent. l understand that certain procedures will require specific informed consent and that Facility will provide me with information and forms prior to such procedures. I grant Facility consent to submit immunizations administered to State Immunization Registry, and to view and\/or import all medication history prescribed within the last two years. I authorize Facility to search for and access my records through a Health Information Exchange (HIE) for purposes of medical treatment. I have the right to opt-out at any time by notifying Facility.\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Patient's Name:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"privacy_patient_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"privacy_patient_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Patient's Representative: (if patient is unable to sign) <span class=\"wpcf7-form-control-wrap\" data-name=\"privacy_patient_rep_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"privacy_patient_rep_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><em>Typing your name above constitutes a legal signature.<\/em>\n\t<\/p>\n<\/fieldset>\n\n<!-- Patient Demographics -->\n<h2>Demographics\n<\/h2>\n<fieldset>\n\t<h4>Patient Information\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Name:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_last_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_last_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>First Name:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_first_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_first_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Middle Name:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_middle_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_middle_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Suffix: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_suffix\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_suffix\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Social Security Number:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_ssn\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_ssn\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Date of Birth:<span class=\"required\">*<\/span> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_DOB\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_DOB\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Primary Care Physician: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_PCP\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_PCP\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Gender\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Marital Status\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient_marital_status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Divorced\" \/><span class=\"wpcf7-list-item-label\">Divorced<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Married\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Separated\" \/><span class=\"wpcf7-list-item-label\">Separated<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Single\" \/><span class=\"wpcf7-list-item-label\">Single<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Widowed\" \/><span class=\"wpcf7-list-item-label\">Widowed<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient_marital_status[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Preferred Language\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient_language\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient_language[]\" value=\"English\" \/><span class=\"wpcf7-list-item-label\">English<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient_language[]\" value=\"Spanish\" \/><span class=\"wpcf7-list-item-label\">Spanish<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Race\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient_race\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient_race[]\" value=\"Asian\" \/><span class=\"wpcf7-list-item-label\">Asian<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_race[]\" value=\"Black\" \/><span class=\"wpcf7-list-item-label\">Black<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"patient_race[]\" value=\"White\" \/><span class=\"wpcf7-list-item-label\">White<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient_race[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Ethnicity\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"patient_ethnicity\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"patient_ethnicity[]\" value=\"Hispanic\" \/><span class=\"wpcf7-list-item-label\">Hispanic<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"patient_ethnicity[]\" value=\"Not Hispanic\" \/><span class=\"wpcf7-list-item-label\">Not Hispanic<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_mailing_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_mailing_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Apartment\/Lot: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_address_apt\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_address_apt\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_city_state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_city_state\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Zip Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_zip_code\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient_zip_code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Phone Numbers:\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Home: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_phone_home\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient_phone_home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mobile: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_phone_mobile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient_phone_mobile\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Work: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_phone_work\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient_phone_work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Email Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"patient_email_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient_email_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>How did you hear about us? <span class=\"wpcf7-form-control-wrap\" data-name=\"referrer\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referrer\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Referring Physician: <span class=\"wpcf7-form-control-wrap\" data-name=\"referring-physician\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referring-physician\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Responsible Party\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rp-same-as-patient\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"rp-same-as-patient[]\" value=\"Responsible Party is the Same as Patient\" \/><span class=\"wpcf7-list-item-label\">Responsible Party is the Same as Patient<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_last_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_last_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>First Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_first_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_first_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Date of Birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_DOB\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_DOB\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship to Patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Gender\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rp_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"rp_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"rp_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_mailing_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_mailing_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Apartment\/Lot: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_address_apt\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_address_apt\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_city_state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_city_state\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Zip Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_zip_code\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rp_zip_code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Phone Numbers:\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Home: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_phone_home\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"rp_phone_home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mobile: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_phone_mobile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"rp_phone_mobile\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Work: <span class=\"wpcf7-form-control-wrap\" data-name=\"rp_phone_work\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"rp_phone_work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Employer Information\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Employer: <span class=\"wpcf7-form-control-wrap\" data-name=\"employer\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"employer_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"employer_city_state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer_city_state\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Zip Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"employer_zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"employer_zip\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Emergency Contact\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ec-same-as-rp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"ec-same-as-rp[]\" value=\"Emergency Contact is the Same as Responsible Party\" \/><span class=\"wpcf7-list-item-label\">Emergency Contact is the Same as Responsible Party<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_last_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_last_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>First Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_first_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_first_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Date of Birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_DOB\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_DOB\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship to Patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Gender\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ec_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"ec_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"ec_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_mailing_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_mailing_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Apartment\/Lot: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_address_apt\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_address_apt\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_city_state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_city_state\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Zip Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_zip_code\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ec_zip_code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Phone Numbers:\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Home: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_phone_home\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"ec_phone_home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mobile: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_phone_mobile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"ec_phone_mobile\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Work: <span class=\"wpcf7-form-control-wrap\" data-name=\"ec_phone_work\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"ec_phone_work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<h4>Guardian Contact\n\t<\/h4>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"guardian-same-as-rp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"guardian-same-as-rp[]\" value=\"Guardian is the Same as Responsible Party\" \/><span class=\"wpcf7-list-item-label\">Guardian is the Same as Responsible Party<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"guardian-same-as-ec\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"guardian-same-as-ec[]\" value=\"Guardian is the Same as Emergency Contact\" \/><span class=\"wpcf7-list-item-label\">Guardian is the Same as Emergency Contact<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Last Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_last_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_last_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>First Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_first_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_first_name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Date of Birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_DOB\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_DOB\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Relationship to Patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_relationship\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Gender\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"guardian_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"guardian_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_mailing_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_mailing_address\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Apartent\/Lot: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_address_apt\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_address_apt\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_city_state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_city_state\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Zip Code: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_zip_code\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"guardian_zip_code\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p>Phone Numbers:\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Home: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_phone_home\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"guardian_phone_home\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Mobile: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_phone_mobile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"guardian_phone_mobile\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Work: <span class=\"wpcf7-form-control-wrap\" data-name=\"guardian_phone_work\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"guardian_phone_work\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Bothered By -->\n<h2>Mental Health\n<\/h2>\n<fieldset>\n\t<p>Over the last 2 weeks, how often have you been bothered by any of the following problems?\n\t<\/p>\n<hr \/>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Little interest or pleasure in doing things\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_1\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_1\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_1\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_1\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_1\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Feeling down, depressed, or hopeless\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_2\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_2\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_2\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_2\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Trouble falling or staying asleep, or sleeping too much\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_3\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_3\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_3\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_3\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_3\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Feeling tired or having little energy\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_4\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_4\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_4\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_4\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_4\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Poor appetite or overeating\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_5\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_5\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_5\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_5\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_5\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Feeling bad about yourself or that you are a failure or have let yourself or your family down\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_6\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_6\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_6\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_6\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_6\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Trouble concentrating on things such as reading the newspaper or watching television.\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_7\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_7\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_7\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_7\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_7\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Moving or speaking so slowly that people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_8\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_8\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_8\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_8\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_8\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>Thoughts that you would be better off dead or of hurting yourself in some way.\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_9\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_9\" value=\"Not at All\" \/><span class=\"wpcf7-list-item-label\">Not at All<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_9\" value=\"Several Days\" \/><span class=\"wpcf7-list-item-label\">Several Days<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_9\" value=\"More Than Half The Days\" \/><span class=\"wpcf7-list-item-label\">More Than Half The Days<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_9\" value=\"Nearly Every Day\" \/><span class=\"wpcf7-list-item-label\">Nearly Every Day<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p>If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at homes, or get along with other people.\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"botheredby_difficulty\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"botheredby_difficulty\" value=\"Not difficult at all\" \/><span class=\"wpcf7-list-item-label\">Not difficult at all<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_difficulty\" value=\"Somewhat difficult\" \/><span class=\"wpcf7-list-item-label\">Somewhat difficult<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"botheredby_difficulty\" value=\"Very difficult\" \/><span class=\"wpcf7-list-item-label\">Very difficult<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"botheredby_difficulty\" value=\"Extremely difficult\" \/><span class=\"wpcf7-list-item-label\">Extremely difficult<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n\n<!-- Insurance Information -->\n<h2>Insurance Information\n<\/h2>\n<fieldset>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"self-pay\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"self-pay[]\" value=\"Check if Self Pay\" \/><span class=\"wpcf7-list-item-label\">Check if Self Pay<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_same_as_rp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"primary_insurance_same_as_rp[]\" value=\"Check if Same as Responsible Party\" \/><span class=\"wpcf7-list-item-label\">Check if Same as Responsible Party<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Subscriber Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_subscriber_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_subscriber_name\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Date of Birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_subscriber_dob\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_subscriber_dob\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Relationship to Patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_subscriber_rel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_subscriber_rel\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<p>Gender\n\t\t\t<\/p>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_subscriber_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"primary_insurance_subscriber_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"primary_insurance_subscriber_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Primary Insurance Company: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_company\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_company\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Begin Date: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_start_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_start_date\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Insurance Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_address\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_city\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Zip: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_zip\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Subscriber #: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_subscriber_number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_subscriber_number\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Group #: <span class=\"wpcf7-form-control-wrap\" data-name=\"primary_insurance_group_number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary_insurance_group_number\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_same_as_rp\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"secondary_insurance_same_as_rp[]\" value=\"Check if Same as Responsible Party\" \/><span class=\"wpcf7-list-item-label\">Check if Same as Responsible Party<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Subscriber Name: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_subscriber_name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_subscriber_name\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Date of Birth: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_subscriber_dob\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_subscriber_dob\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Relationship to Patient: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_subscriber_rel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_subscriber_rel\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<p>Gender\n\t\t\t<\/p>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\" style=\"flex-grow:0;\">\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_subscriber_gender\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"secondary_insurance_subscriber_gender[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"secondary_insurance_subscriber_gender[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Secondary Insurance Company: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_company\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_company\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Begin Date: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_start_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_start_date\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Insurance Mailing Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_address\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>City\/State: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_city\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Zip: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_zip\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div class=\"cf7-row\">\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Subscriber #: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_subscriber_number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_subscriber_number\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"cf7-col\">\n\t\t\t\t\t<p><label>Group #: <span class=\"wpcf7-form-control-wrap\" data-name=\"secondary_insurance_group_number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"secondary_insurance_group_number\" \/><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Patient\/Guardian Signature <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance_signature\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance_signature\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><label>Date <span class=\"wpcf7-form-control-wrap\" data-name=\"insurance_signature_date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"insurance_signature_date\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><em>Typing your name above constitutes a legal signature.<\/em>\n\t<\/p>\n\t<div class=\"cf7-row\">\n\t\t<div class=\"cf7-col\">\n\t\t\t<p><a href=\"https:\/\/bestcoastinternalmedicine.com\/wp-content\/uploads\/2024\/02\/BCIM-Privacy-Notice.pdf\" target=\"_blank\">Click here to view and read the Best Coast Internal Medicine Privacy Notice<\/a>\n\t\t\t<\/p>\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"privacy-acknowledgement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"privacy-acknowledgement[]\" value=\"I have read and understand the Best Coast Internal Medicine Privacy Notice\" \/><span class=\"wpcf7-list-item-label\">I have read and understand the Best Coast Internal Medicine Privacy Notice<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/fieldset>\n<input class=\"wpcf7-form-control wpcf7-hidden\" value=\"\" type=\"hidden\" name=\"empty_field\" \/>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Form\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"126\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>New Patient Form - Best Coast Internal Medicine<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/bestcoastinternalmedicine.com\/new-patient-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"New Patient Form - Best Coast Internal Medicine\" \/>\n<meta property=\"og:url\" content=\"https:\/\/bestcoastinternalmedicine.com\/new-patient-form\/\" \/>\n<meta property=\"og:site_name\" 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