{"id":2700,"date":"2025-04-28T16:03:45","date_gmt":"2025-04-28T20:03:45","guid":{"rendered":"https:\/\/www.cliniquepodiatriquederepentigny.com\/medical-questionnaire\/"},"modified":"2025-10-08T12:35:38","modified_gmt":"2025-10-08T16:35:38","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/medical-questionnaire\/","title":{"rendered":"Medical Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2700\" class=\"elementor elementor-2700 elementor-2541\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-52e427e elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"52e427e\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-cc4a9a0\" data-id=\"cc4a9a0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-96d834b animated-slow elementor-widget__width-auto elementor-widget elementor-widget-heading\" data-id=\"96d834b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Medical Questionnaire<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1c8a356c animated-slow elementor-widget elementor-widget-heading\" data-id=\"1c8a356c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">New patients<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7dfe30c elementor-widget elementor-widget-text-editor\" data-id=\"7dfe30c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>For your first visit, it&#8217;s important that you fill in a form providing us with all the information about your health. To speed up the process, we invite you to complete the form before your appointment.<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-75284241 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"75284241\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7cceabd9\" data-id=\"7cceabd9\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3caa7c0 elementor-widget elementor-widget-wpforms\" data-id=\"3caa7c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-elementor-widget-3caa7c0\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-3caa7c0 {\n\t\t\t\t--wpforms-button-background-color: #008499;\n--wpforms-field-text-color: #49444CBD;\n--wpforms-label-color: #49444CF7;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2535\"><form id=\"wpforms-form-2535\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2535\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/2700\" data-token=\"eba233fd8a4f6623c97d34e27bce1456\" data-token-time=\"1781523330\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2535-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><fieldset><legend class=\"wpforms-field-label\">Patient Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-2535-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" aria-errormessage=\"wpforms-2535-field_0-error\" required><label for=\"wpforms-2535-field_0\" class=\"wpforms-field-sublabel after\">First name<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2535-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" aria-errormessage=\"wpforms-2535-field_0-last-error\" required><label for=\"wpforms-2535-field_0-last\" class=\"wpforms-field-sublabel after\">Last name<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2535-field_45-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"45\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_46-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_46\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2535-field_46\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][46]\" spellcheck=\"false\" aria-errormessage=\"wpforms-2535-field_46-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2535-field_47-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_47\">Cellular <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2535-field_47\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][47]\" aria-label=\"Cellular\" aria-errormessage=\"wpforms-2535-field_47-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2535-field_48-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_48\">Home phone<\/label><input type=\"tel\" id=\"wpforms-2535-field_48\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][48]\" aria-label=\"Home phone\" aria-errormessage=\"wpforms-2535-field_48-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_7-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-2535-field_7\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][7][address1]\" aria-errormessage=\"wpforms-2535-field_7-error\" required><label for=\"wpforms-2535-field_7\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2535-field_7-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][7][city]\" aria-errormessage=\"wpforms-2535-field_7-city-error\" required><label for=\"wpforms-2535-field_7-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2535-field_7-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][7][state]\" value=\"Qu\u00e9bec\" aria-errormessage=\"wpforms-2535-field_7-state-error\" required><label for=\"wpforms-2535-field_7-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2535-field_7-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][7][postal]\" aria-errormessage=\"wpforms-2535-field_7-postal-error\" required><label for=\"wpforms-2535-field_7-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-2535-field_42-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"42\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_50-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][50][date][d]\" id=\"wpforms-2535-field_50-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][50][date][m]\" id=\"wpforms-2535-field_50-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][50][date][y]\" id=\"wpforms-2535-field_50-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_11\">Type <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"Man\"  class=\"choice-1 depth-1\"  >Man<\/option><option value=\"Woman\"  class=\"choice-2 depth-1\"  >Woman<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_49\">Referred by<\/label><input type=\"text\" id=\"wpforms-2535-field_49\" class=\"wpforms-field-medium\" name=\"wpforms[fields][49]\" aria-errormessage=\"wpforms-2535-field_49-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_75\">RAMQ number<\/label><input type=\"text\" id=\"wpforms-2535-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-2535-field_75-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_52-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"52\"><fieldset><legend class=\"wpforms-field-label\">Exp RAMQ<\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][52][date][d]\" id=\"wpforms-2535-field_52-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][52][date][m]\" id=\"wpforms-2535-field_52-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][52][date][y]\" id=\"wpforms-2535-field_52-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_53\">Occupation<\/label><input type=\"text\" id=\"wpforms-2535-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-2535-field_53-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_55\">Size <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2535-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-2535-field_55-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_56-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_56\">Weight (lbs) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-2535-field_56\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][56]\" step=\"any\" aria-errormessage=\"wpforms-2535-field_56-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_57-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_57\">Shoe size <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-2535-field_57\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][57]\" step=\"any\" aria-errormessage=\"wpforms-2535-field_57-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_13-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"13\"><h3 id=\"wpforms-2535-field_13\" aria-errormessage=\"wpforms-2535-field_13-error\">Medical information<\/h3><\/div><div id=\"wpforms-2535-field_58-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"58\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-2535-field_14-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_14\">First and last name of your family doctor <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2535-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-2535-field_14-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_77-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"77\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-2535-field_79-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_79\">Name of your pharmacy <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2535-field_79\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][79]\" aria-errormessage=\"wpforms-2535-field_79-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_80-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_80\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-2535-field_80\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][80]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-2535-field_80-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_62-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"62\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_63-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_63\">Are you taking anticoagulants? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_63\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][63]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_19\">Are you taking any medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_20-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_20\">Which ones?<\/label><textarea id=\"wpforms-2535-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-2535-field_20-error\" aria-describedby=\"wpforms-2535-field_20-description\" ><\/textarea><div id=\"wpforms-2535-field_20-description\" class=\"wpforms-field-description\">Provide medication list as needed<\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_64-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"64\"><fieldset><legend class=\"wpforms-field-label\">Present health problems<\/legend><ul id=\"wpforms-2535-field_64\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_1\" name=\"wpforms[fields][64][]\" value=\"Heart\" aria-errormessage=\"wpforms-2535-field_64_1-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_1\">Heart<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_2\" name=\"wpforms[fields][64][]\" value=\"Diabetes\" aria-errormessage=\"wpforms-2535-field_64_2-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_2\">Diabetes<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_3\" name=\"wpforms[fields][64][]\" value=\"Drop\" aria-errormessage=\"wpforms-2535-field_64_3-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_3\">Drop<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_4\" name=\"wpforms[fields][64][]\" value=\"Arthritis\" aria-errormessage=\"wpforms-2535-field_64_4-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_4\">Arthritis<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_5\" name=\"wpforms[fields][64][]\" value=\"Cancer\" aria-errormessage=\"wpforms-2535-field_64_5-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_5\">Cancer<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_6\" name=\"wpforms[fields][64][]\" value=\"Asthma\" aria-errormessage=\"wpforms-2535-field_64_6-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_6\">Asthma<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_7\" name=\"wpforms[fields][64][]\" value=\"Thyroid gland\" aria-errormessage=\"wpforms-2535-field_64_7-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_7\">Thyroid gland<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_8\" name=\"wpforms[fields][64][]\" value=\"Osteoarthritis\" aria-errormessage=\"wpforms-2535-field_64_8-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_8\">Osteoarthritis<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_9\" name=\"wpforms[fields][64][]\" value=\"Hypertension\" aria-errormessage=\"wpforms-2535-field_64_9-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_9\">Hypertension<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_10\" name=\"wpforms[fields][64][]\" value=\"Nervous system\" aria-errormessage=\"wpforms-2535-field_64_10-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_10\">Nervous system<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_11\" name=\"wpforms[fields][64][]\" value=\"HIV-positive\/AIDS\" aria-errormessage=\"wpforms-2535-field_64_11-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_11\">HIV-positive\/AIDS<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_64_12\" name=\"wpforms[fields][64][]\" value=\"Other\" aria-errormessage=\"wpforms-2535-field_64_12-error\" aria-describedby=\"wpforms-2535-field_64-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_64_12\">Other<\/label><\/li><\/ul><div id=\"wpforms-2535-field_64-description\" class=\"wpforms-field-description\">Tick, if applicable.<\/div><\/fieldset><\/div><div id=\"wpforms-2535-field_66-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"66\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_65-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_65\">Do you have flu symptoms? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_65\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][65]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2535-field_67-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_67\">Are you pregnant? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_67\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][67]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-25\"><div id=\"wpforms-2535-field_68-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_68\">Were you breastfeeding? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_68\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][68]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_69-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"69\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_21-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_21\">Previous surgery? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_22-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_22\">Which ones?<\/label><textarea id=\"wpforms-2535-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-2535-field_22-error\" ><\/textarea><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_27-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_27\">Do you have any allergies? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_28-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_28\">Which ones?<\/label><textarea id=\"wpforms-2535-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-2535-field_28-error\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-2535-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_29\">Are there any other disabilities or conditions not mentioned above? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required=\"required\"><option value=\"No\"  class=\"choice-1 depth-1\"  >No<\/option><option value=\"Yes\"  class=\"choice-2 depth-1\"  >Yes<\/option><\/select><\/div><div id=\"wpforms-2535-field_30-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_30\">Which ones?<\/label><textarea id=\"wpforms-2535-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-2535-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-2535-field_71-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"71\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-2535-field_70-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_70\">Reasons for consultation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2535-field_70\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][70]\" required=\"required\"><option value=\"Callus\"  class=\"choice-1 depth-1\"  >Callus<\/option><option value=\"Mushroom\"  class=\"choice-2 depth-1\"  >Mushroom<\/option><option value=\"Wart\"  class=\"choice-3 depth-1\"  >Wart<\/option><option value=\"Ingrown toenail\"  class=\"choice-4 depth-1\"  >Ingrown toenail<\/option><option value=\"Pain\"  class=\"choice-5 depth-1\"  >Pain<\/option><option value=\"Flat feet\"  class=\"choice-6 depth-1\"  >Flat feet<\/option><option value=\"Other\"  class=\"choice-7 depth-1\"  >Other<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-2535-field_72-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_72\">Since then?<\/label><input type=\"text\" id=\"wpforms-2535-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" aria-errormessage=\"wpforms-2535-field_72-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-67\"><div id=\"wpforms-2535-field_81-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"81\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_81\">Please specify<\/label><input type=\"text\" id=\"wpforms-2535-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" aria-errormessage=\"wpforms-2535-field_81-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-2535-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-2535-field_1\" >patient layout Are<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-2535-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-2535-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Declaration of consent <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2535-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2535-field_9_1\" name=\"wpforms[fields][9][]\" value=\"I confirm that the information provided is accurate and complete. I authorize the transmission of this information to clinic personnel for the evaluation and management of my medical condition.\" aria-errormessage=\"wpforms-2535-field_9_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2535-field_9_1\">I confirm that the information provided is accurate and complete. I authorize the transmission of this information to clinic personnel for the evaluation and management of my medical condition.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2535-field_31-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_31\">Signature of patient or guardian <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2535-field_31\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][31]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-2535-field_31-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-2535-field_31-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-2535-field_73-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"73\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_74-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_74\">Name of patient or guardian (if minor) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2535-field_74\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][74]\" aria-errormessage=\"wpforms-2535-field_74-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_32-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_32\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2535-field_32\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][32][date]\" aria-errormessage=\"wpforms-2535-field_32-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-2535-field_82-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-2535-field_82\">Tutor&#039;s telephone number (if different from above)<\/label><input type=\"tel\" id=\"wpforms-2535-field_82\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][82]\" aria-label=\"Tutor&#039;s telephone number (if different from above)\" aria-errormessage=\"wpforms-2535-field_82-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-2535-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-2535-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-2535-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2535\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/pages\/2700\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2535\" class=\"wpforms-submit\" data-alt-text=\"Send...\" data-submit-text=\"Send\" aria-live=\"assertive\" value=\"wpforms-submit\">Send<\/button><img decoding=\"async\" src=\"https:\/\/www.cliniquepodiatriquederepentigny.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c3d3284 elementor-widget elementor-widget-heading\" data-id=\"c3d3284\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">If you are unable to keep your appointment, you must notify us at least 48 hours in advance, otherwise you will have to pay a fee of $60.<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-17a6326b elementor-widget elementor-widget-heading\" data-id=\"17a6326b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">PODIATRIC CARE IS NOT COVERED BY THE R\u00c9GIE DE L'ASSURANCE-MALADIE DU QU\u00c9BEC<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Medical Questionnaire New patients For your first visit, it&#8217;s important that you fill in a form providing us with all the information about your health. To speed up the process, we invite you to complete the form before your appointment. Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.Veuillez activer JavaScript dans votre navigateur [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"unboxed","site-sidebar-style":"unboxed","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"disabled","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"default","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-2700","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/pages\/2700","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/comments?post=2700"}],"version-history":[{"count":3,"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/pages\/2700\/revisions"}],"predecessor-version":[{"id":2997,"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/pages\/2700\/revisions\/2997"}],"wp:attachment":[{"href":"https:\/\/www.cliniquepodiatriquederepentigny.com\/en\/wp-json\/wp\/v2\/media?parent=2700"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}