{"id":6260,"date":"2020-06-29T15:57:10","date_gmt":"2020-06-29T15:57:10","guid":{"rendered":"https:\/\/bellaradiance.com\/?page_id=6260"},"modified":"2020-06-29T15:57:10","modified_gmt":"2020-06-29T15:57:10","slug":"medical-history-form","status":"publish","type":"page","link":"https:\/\/bellaradiance.com\/medical-history-form\/","title":{"rendered":"Medical History Form"},"content":{"rendered":"<h1>\n\t\tMEDICAL HISTORY FORM\n\t<\/h1>\n\t<div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.7\" data-cf-form-id=\"CF5efa0ad158414\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/bellaradiance.com\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF5efa0ad158414 caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF5efa0ad158414_1\" data-form-id=\"CF5efa0ad158414\" aria-label=\"Medical History Form\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF5efa0ad158414-tmpl\" data-cfajax=\"CF5efa0ad158414\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/bellaradiance.com\/cf-api\/CF5efa0ad158414\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF5efa0ad158414\" name=\"_cf_verify\" value=\"2127d41be5\"  data-nonce-time=\"1712207682\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/6260\" \/><div id=\"cf2-CF5efa0ad158414_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF5efa0ad158414\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF5efa0ad158414\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"6260\">\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Phone<\/label><input type=\"text\" name=\"phone\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"CF5efa0ad158414_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-12  single\"><div class=\"\"><h2>Your Details<\/h2>\n<\/div><\/div><\/div><div id=\"CF5efa0ad158414_1-row-2\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8768091\" class=\"form-group\" id=\"fld_8768091_1-wrap\">\r\n\t<label id=\"fld_8768091Label\" for=\"fld_8768091_1\" class=\"control-label\">First Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_8768091\" class=\" form-control\" id=\"fld_8768091_1\" name=\"fld_8768091\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_8768091Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_9970286\" class=\"form-group\" id=\"fld_9970286_1-wrap\">\r\n\t<label id=\"fld_9970286Label\" for=\"fld_9970286_1\" class=\"control-label\">Last Name <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_9970286\" class=\" form-control\" id=\"fld_9970286_1\" name=\"fld_9970286\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9970286Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-3\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_6009157\" class=\"form-group\" id=\"fld_6009157_1-wrap\">\r\n\t<label id=\"fld_6009157Label\" for=\"fld_6009157_1\" class=\"control-label\">Email Address <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_6009157\" class=\" form-control\" id=\"fld_6009157_1\" name=\"fld_6009157\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_6009157Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3582427\" class=\"form-group\" id=\"fld_3582427_1-wrap\">\r\n\t<label id=\"fld_3582427Label\" for=\"fld_3582427_1\" class=\"control-label\">Phone Number<\/label>\r\n\t<div class=\"\">\r\n\t\t<input    type=\"tel\" data-field=\"fld_3582427\" class=\" form-control\" id=\"fld_3582427_1\" name=\"fld_3582427\" value=\"\" data-type=\"phone_better\"   aria-labelledby=\"fld_3582427Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-4\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_7416992\" class=\"form-group\" id=\"fld_7416992_1-wrap\">\r\n\t<label id=\"fld_7416992Label\" for=\"fld_7416992_1\" class=\"control-label\">Address <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7416992\" value=\"\" data-field=\"fld_7416992\" class=\"form-control\" id=\"fld_7416992_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_7416992Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_232718\" class=\"form-group\" id=\"fld_232718_1-wrap\">\r\n\t<label id=\"fld_232718Label\" for=\"fld_232718_1\" class=\"control-label\">Post Code <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_232718\" class=\" form-control\" id=\"fld_232718_1\" name=\"fld_232718\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_232718Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-5\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2165115\" class=\"form-group\" id=\"fld_2165115_1-wrap\">\r\n\t<label id=\"fld_2165115Label\" for=\"fld_2165115_1\" class=\"control-label\">Doctors Name & Address <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_2165115\" value=\"\" data-field=\"fld_2165115\" class=\"form-control\" id=\"fld_2165115_1\" rows=\"4\"  required=\"required\"  aria-labelledby=\"fld_2165115Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_37501\" class=\"form-group\" id=\"fld_37501_1-wrap\">\r\n\t<label id=\"fld_37501Label\" for=\"fld_37501_1\" class=\"control-label\">Occupation <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"text\" data-field=\"fld_37501\" class=\" form-control\" id=\"fld_37501_1\" name=\"fld_37501\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_37501Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-6\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><p>It is important, for your benefit, that your dentist knows certain things about your general health.<br \/>\n<br \/>\n<b><Br>It would be appreciated therefore if you would answer each of the questions below by ticking \u201cyes\u201d or \u201cno\u201d and giving details below where appropriate. Your co-operation is much appreciated.<\/br><\/b><\/p>\n<\/div><\/div><\/div><div id=\"CF5efa0ad158414_1-row-7\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_3857974\" class=\"form-group cf-toggle-switch\" id=\"fld_3857974_1-wrap\">\r\n\t<label id=\"fld_3857974Label\" for=\"fld_3857974_1\" class=\"control-label\">Are you recieving treatment from a hospital, doctor or clinic?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_3857974_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_3857974\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_3857974Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_3857974_1_opt1569293\" data-label=\"No\" data-field=\"fld_3857974\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_3857974Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_3857974_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_3857974\" data-ref=\"fld_3857974_1_opt1282135\" class=\"cf-toggle-group-radio fld_3857974_1\" name=\"fld_3857974\" value=\"Yes\"  data-radio-field=\"fld_3857974_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_3857974_1_opt1569293\" data-label=\"No\" data-field=\"fld_3857974\" data-ref=\"fld_3857974_1_opt1569293\" class=\"cf-toggle-group-radio fld_3857974_1\" name=\"fld_3857974\" value=\"No\"  data-radio-field=\"fld_3857974_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6913572\" class=\"form-group cf-toggle-switch\" id=\"fld_6913572_1-wrap\">\r\n\t<label id=\"fld_6913572Label\" for=\"fld_6913572_1\" class=\"control-label\">Are you taking any medicines prescribed by your doctor?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_6913572_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_6913572\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_6913572Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_6913572_1_opt1569293\" data-label=\"No\" data-field=\"fld_6913572\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_6913572Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_6913572_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_6913572\" data-ref=\"fld_6913572_1_opt1282135\" class=\"cf-toggle-group-radio fld_6913572_1\" name=\"fld_6913572\" value=\"Yes\"  data-radio-field=\"fld_6913572_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_6913572_1_opt1569293\" data-label=\"No\" data-field=\"fld_6913572\" data-ref=\"fld_6913572_1_opt1569293\" class=\"cf-toggle-group-radio fld_6913572_1\" name=\"fld_6913572\" value=\"No\"  data-radio-field=\"fld_6913572_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7764898\" class=\"form-group cf-toggle-switch\" id=\"fld_7764898_1-wrap\">\r\n\t<label id=\"fld_7764898Label\" for=\"fld_7764898_1\" class=\"control-label\">Are you taking (or have taken) steroids in the last two years?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_7764898_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_7764898\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_7764898Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_7764898_1_opt1569293\" data-label=\"No\" data-field=\"fld_7764898\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_7764898Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7764898_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_7764898\" data-ref=\"fld_7764898_1_opt1282135\" class=\"cf-toggle-group-radio fld_7764898_1\" name=\"fld_7764898\" value=\"Yes\"  data-radio-field=\"fld_7764898_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7764898_1_opt1569293\" data-label=\"No\" data-field=\"fld_7764898\" data-ref=\"fld_7764898_1_opt1569293\" class=\"cf-toggle-group-radio fld_7764898_1\" name=\"fld_7764898\" value=\"No\"  data-radio-field=\"fld_7764898_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5550606\" class=\"form-group cf-toggle-switch\" id=\"fld_5550606_1-wrap\">\r\n\t<label id=\"fld_5550606Label\" for=\"fld_5550606_1\" class=\"control-label\">Are you receiving or taking bisphosphonates by infusion or tablets?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_5550606_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_5550606\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_5550606Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_5550606_1_opt1569293\" data-label=\"No\" data-field=\"fld_5550606\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_5550606Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5550606_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_5550606\" data-ref=\"fld_5550606_1_opt1282135\" class=\"cf-toggle-group-radio fld_5550606_1\" name=\"fld_5550606\" value=\"Yes\"  data-radio-field=\"fld_5550606_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5550606_1_opt1569293\" data-label=\"No\" data-field=\"fld_5550606\" data-ref=\"fld_5550606_1_opt1569293\" class=\"cf-toggle-group-radio fld_5550606_1\" name=\"fld_5550606\" value=\"No\"  data-radio-field=\"fld_5550606_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9718767\" class=\"form-group cf-toggle-switch\" id=\"fld_9718767_1-wrap\">\r\n\t<label id=\"fld_9718767Label\" for=\"fld_9718767_1\" class=\"control-label\">Are you allergic to any medicines or materials e.g. antibiotics or latex?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_9718767_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_9718767\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_9718767Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_9718767_1_opt1569293\" data-label=\"No\" data-field=\"fld_9718767\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_9718767Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9718767_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_9718767\" data-ref=\"fld_9718767_1_opt1282135\" class=\"cf-toggle-group-radio fld_9718767_1\" name=\"fld_9718767\" value=\"Yes\"  data-radio-field=\"fld_9718767_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9718767_1_opt1569293\" data-label=\"No\" data-field=\"fld_9718767\" data-ref=\"fld_9718767_1_opt1569293\" class=\"cf-toggle-group-radio fld_9718767_1\" name=\"fld_9718767\" value=\"No\"  data-radio-field=\"fld_9718767_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7475858\" class=\"form-group cf-toggle-switch\" id=\"fld_7475858_1-wrap\">\r\n\t<label id=\"fld_7475858Label\" for=\"fld_7475858_1\" class=\"control-label\">Are you pregnant or have you had a baby in the last 12 months?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_7475858_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_7475858\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_7475858Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_7475858_1_opt1569293\" data-label=\"No\" data-field=\"fld_7475858\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_7475858Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7475858_1_opt1282135\" data-label=\"Yes\" data-field=\"fld_7475858\" data-ref=\"fld_7475858_1_opt1282135\" class=\"cf-toggle-group-radio fld_7475858_1\" name=\"fld_7475858\" value=\"Yes\"  data-radio-field=\"fld_7475858_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7475858_1_opt1569293\" data-label=\"No\" data-field=\"fld_7475858\" data-ref=\"fld_7475858_1_opt1569293\" class=\"cf-toggle-group-radio fld_7475858_1\" name=\"fld_7475858\" value=\"No\"  data-radio-field=\"fld_7475858_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9171000\" class=\"form-group\" id=\"fld_9171000_1-wrap\">\r\n\t<label id=\"fld_9171000Label\" for=\"fld_9171000_1\" class=\"control-label\">Please provide details for any<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9171000\" value=\"\" data-field=\"fld_9171000\" class=\"form-control\" id=\"fld_9171000_1\" rows=\"4\"    aria-labelledby=\"fld_9171000Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-8\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9655934\" class=\"form-group cf-toggle-switch\" id=\"fld_9655934_1-wrap\">\r\n\t<label id=\"fld_9655934Label\" for=\"fld_9655934_1\" class=\"control-label\">Have you had Rheumatic Fever?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_9655934_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9655934\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_9655934Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_9655934_1_opt1940474\" data-label=\"No\" data-field=\"fld_9655934\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_9655934Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9655934_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9655934\" data-ref=\"fld_9655934_1_opt1843828\" class=\"cf-toggle-group-radio fld_9655934_1\" name=\"fld_9655934\" value=\"Yes\"  data-radio-field=\"fld_9655934_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9655934_1_opt1940474\" data-label=\"No\" data-field=\"fld_9655934\" data-ref=\"fld_9655934_1_opt1940474\" class=\"cf-toggle-group-radio fld_9655934_1\" name=\"fld_9655934\" value=\"No\"  data-radio-field=\"fld_9655934_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_6106265\" class=\"form-group cf-toggle-switch\" id=\"fld_6106265_1-wrap\">\r\n\t<label id=\"fld_6106265Label\" for=\"fld_6106265_1\" class=\"control-label\">Have you had Jaundice, liver, kidney disease or hepatitis?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_6106265_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_6106265\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_6106265Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_6106265_1_opt1940474\" data-label=\"No\" data-field=\"fld_6106265\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_6106265Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_6106265_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_6106265\" data-ref=\"fld_6106265_1_opt1843828\" class=\"cf-toggle-group-radio fld_6106265_1\" name=\"fld_6106265\" value=\"Yes\"  data-radio-field=\"fld_6106265_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_6106265_1_opt1940474\" data-label=\"No\" data-field=\"fld_6106265\" data-ref=\"fld_6106265_1_opt1940474\" class=\"cf-toggle-group-radio fld_6106265_1\" name=\"fld_6106265\" value=\"No\"  data-radio-field=\"fld_6106265_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2858678\" class=\"form-group cf-toggle-switch\" id=\"fld_2858678_1-wrap\">\r\n\t<label id=\"fld_2858678Label\" for=\"fld_2858678_1\" class=\"control-label\">Have you ever been told you have a heart problem, angina, or high blood pressure?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_2858678_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2858678\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_2858678Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_2858678_1_opt1940474\" data-label=\"No\" data-field=\"fld_2858678\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_2858678Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2858678_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2858678\" data-ref=\"fld_2858678_1_opt1843828\" class=\"cf-toggle-group-radio fld_2858678_1\" name=\"fld_2858678\" value=\"Yes\"  data-radio-field=\"fld_2858678_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2858678_1_opt1940474\" data-label=\"No\" data-field=\"fld_2858678\" data-ref=\"fld_2858678_1_opt1940474\" class=\"cf-toggle-group-radio fld_2858678_1\" name=\"fld_2858678\" value=\"No\"  data-radio-field=\"fld_2858678_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2338808\" class=\"form-group cf-toggle-switch\" id=\"fld_2338808_1-wrap\">\r\n\t<label id=\"fld_2338808Label\" for=\"fld_2338808_1\" class=\"control-label\">Have you ever had a bad reaction to local anaesthetic?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_2338808_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2338808\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_2338808Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_2338808_1_opt1940474\" data-label=\"No\" data-field=\"fld_2338808\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_2338808Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2338808_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2338808\" data-ref=\"fld_2338808_1_opt1843828\" class=\"cf-toggle-group-radio fld_2338808_1\" name=\"fld_2338808\" value=\"Yes\"  data-radio-field=\"fld_2338808_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2338808_1_opt1940474\" data-label=\"No\" data-field=\"fld_2338808\" data-ref=\"fld_2338808_1_opt1940474\" class=\"cf-toggle-group-radio fld_2338808_1\" name=\"fld_2338808\" value=\"No\"  data-radio-field=\"fld_2338808_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5597022\" class=\"form-group cf-toggle-switch\" id=\"fld_5597022_1-wrap\">\r\n\t<label id=\"fld_5597022Label\" for=\"fld_5597022_1\" class=\"control-label\">Have you ever a joint replacement or other implant?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_5597022_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5597022\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_5597022Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_5597022_1_opt1940474\" data-label=\"No\" data-field=\"fld_5597022\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_5597022Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5597022_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5597022\" data-ref=\"fld_5597022_1_opt1843828\" class=\"cf-toggle-group-radio fld_5597022_1\" name=\"fld_5597022\" value=\"Yes\"  data-radio-field=\"fld_5597022_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5597022_1_opt1940474\" data-label=\"No\" data-field=\"fld_5597022\" data-ref=\"fld_5597022_1_opt1940474\" class=\"cf-toggle-group-radio fld_5597022_1\" name=\"fld_5597022\" value=\"No\"  data-radio-field=\"fld_5597022_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9198337\" class=\"form-group cf-toggle-switch\" id=\"fld_9198337_1-wrap\">\r\n\t<label id=\"fld_9198337Label\" for=\"fld_9198337_1\" class=\"control-label\">Have you ever hospitalised? If YES for what and when?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_9198337_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9198337\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_9198337Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_9198337_1_opt1940474\" data-label=\"No\" data-field=\"fld_9198337\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_9198337Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9198337_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9198337\" data-ref=\"fld_9198337_1_opt1843828\" class=\"cf-toggle-group-radio fld_9198337_1\" name=\"fld_9198337\" value=\"Yes\"  data-radio-field=\"fld_9198337_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9198337_1_opt1940474\" data-label=\"No\" data-field=\"fld_9198337\" data-ref=\"fld_9198337_1_opt1940474\" class=\"cf-toggle-group-radio fld_9198337_1\" name=\"fld_9198337\" value=\"No\"  data-radio-field=\"fld_9198337_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_9670758\" class=\"form-group\" id=\"fld_9670758_1-wrap\">\r\n\t<label id=\"fld_9670758Label\" for=\"fld_9670758_1\" class=\"control-label\">Please provide details for any<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_9670758\" value=\"\" data-field=\"fld_9670758\" class=\"form-control\" id=\"fld_9670758_1\" rows=\"4\"    aria-labelledby=\"fld_9670758Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-9\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_9023391\" class=\"form-group cf-toggle-switch\" id=\"fld_9023391_1-wrap\">\r\n\t<label id=\"fld_9023391Label\" for=\"fld_9023391_1\" class=\"control-label\">Do you have arthritis?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_9023391_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9023391\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_9023391Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_9023391_1_opt1940474\" data-label=\"No\" data-field=\"fld_9023391\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_9023391Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9023391_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_9023391\" data-ref=\"fld_9023391_1_opt1843828\" class=\"cf-toggle-group-radio fld_9023391_1\" name=\"fld_9023391\" value=\"Yes\"  data-radio-field=\"fld_9023391_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_9023391_1_opt1940474\" data-label=\"No\" data-field=\"fld_9023391\" data-ref=\"fld_9023391_1_opt1940474\" class=\"cf-toggle-group-radio fld_9023391_1\" name=\"fld_9023391\" value=\"No\"  data-radio-field=\"fld_9023391_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_473348\" class=\"form-group cf-toggle-switch\" id=\"fld_473348_1-wrap\">\r\n\t<label id=\"fld_473348Label\" for=\"fld_473348_1\" class=\"control-label\">Do you have a Pacemaker?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_473348_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_473348\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_473348Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_473348_1_opt1940474\" data-label=\"No\" data-field=\"fld_473348\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_473348Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_473348_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_473348\" data-ref=\"fld_473348_1_opt1843828\" class=\"cf-toggle-group-radio fld_473348_1\" name=\"fld_473348\" value=\"Yes\"  data-radio-field=\"fld_473348_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_473348_1_opt1940474\" data-label=\"No\" data-field=\"fld_473348\" data-ref=\"fld_473348_1_opt1940474\" class=\"cf-toggle-group-radio fld_473348_1\" name=\"fld_473348\" value=\"No\"  data-radio-field=\"fld_473348_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_2302956\" class=\"form-group cf-toggle-switch\" id=\"fld_2302956_1-wrap\">\r\n\t<label id=\"fld_2302956Label\" for=\"fld_2302956_1\" class=\"control-label\">Do you suffer from hay fever, eczema, or any other allergy?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_2302956_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2302956\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_2302956Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_2302956_1_opt1940474\" data-label=\"No\" data-field=\"fld_2302956\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_2302956Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2302956_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_2302956\" data-ref=\"fld_2302956_1_opt1843828\" class=\"cf-toggle-group-radio fld_2302956_1\" name=\"fld_2302956\" value=\"Yes\"  data-radio-field=\"fld_2302956_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_2302956_1_opt1940474\" data-label=\"No\" data-field=\"fld_2302956\" data-ref=\"fld_2302956_1_opt1940474\" class=\"cf-toggle-group-radio fld_2302956_1\" name=\"fld_2302956\" value=\"No\"  data-radio-field=\"fld_2302956_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5213134\" class=\"form-group cf-toggle-switch\" id=\"fld_5213134_1-wrap\">\r\n\t<label id=\"fld_5213134Label\" for=\"fld_5213134_1\" class=\"control-label\">Do you suffer from bronchitis, asthma, or any other chest condition?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_5213134_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5213134\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_5213134Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_5213134_1_opt1940474\" data-label=\"No\" data-field=\"fld_5213134\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_5213134Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5213134_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5213134\" data-ref=\"fld_5213134_1_opt1843828\" class=\"cf-toggle-group-radio fld_5213134_1\" name=\"fld_5213134\" value=\"Yes\"  data-radio-field=\"fld_5213134_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5213134_1_opt1940474\" data-label=\"No\" data-field=\"fld_5213134\" data-ref=\"fld_5213134_1_opt1940474\" class=\"cf-toggle-group-radio fld_5213134_1\" name=\"fld_5213134\" value=\"No\"  data-radio-field=\"fld_5213134_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_625093\" class=\"form-group cf-toggle-switch\" id=\"fld_625093_1-wrap\">\r\n\t<label id=\"fld_625093Label\" for=\"fld_625093_1\" class=\"control-label\">Do you have diabetes?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_625093_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_625093\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_625093Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_625093_1_opt1940474\" data-label=\"No\" data-field=\"fld_625093\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_625093Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_625093_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_625093\" data-ref=\"fld_625093_1_opt1843828\" class=\"cf-toggle-group-radio fld_625093_1\" name=\"fld_625093\" value=\"Yes\"  data-radio-field=\"fld_625093_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_625093_1_opt1940474\" data-label=\"No\" data-field=\"fld_625093\" data-ref=\"fld_625093_1_opt1940474\" class=\"cf-toggle-group-radio fld_625093_1\" name=\"fld_625093\" value=\"No\"  data-radio-field=\"fld_625093_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_5452263\" class=\"form-group cf-toggle-switch\" id=\"fld_5452263_1-wrap\">\r\n\t<label id=\"fld_5452263Label\" for=\"fld_5452263_1\" class=\"control-label\">Do you have persistent bleeding following injury,tooth extraction or surgery?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_5452263_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5452263\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_5452263Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_5452263_1_opt1940474\" data-label=\"No\" data-field=\"fld_5452263\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_5452263Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5452263_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_5452263\" data-ref=\"fld_5452263_1_opt1843828\" class=\"cf-toggle-group-radio fld_5452263_1\" name=\"fld_5452263\" value=\"Yes\"  data-radio-field=\"fld_5452263_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_5452263_1_opt1940474\" data-label=\"No\" data-field=\"fld_5452263\" data-ref=\"fld_5452263_1_opt1940474\" class=\"cf-toggle-group-radio fld_5452263_1\" name=\"fld_5452263\" value=\"No\"  data-radio-field=\"fld_5452263_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_7270164\" class=\"form-group cf-toggle-switch\" id=\"fld_7270164_1-wrap\">\r\n\t<label id=\"fld_7270164Label\" for=\"fld_7270164_1\" class=\"control-label\">Do you suffer from any infectious disease (including H.I.V)?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_7270164_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_7270164\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_7270164Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_7270164_1_opt1940474\" data-label=\"No\" data-field=\"fld_7270164\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_7270164Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7270164_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_7270164\" data-ref=\"fld_7270164_1_opt1843828\" class=\"cf-toggle-group-radio fld_7270164_1\" name=\"fld_7270164\" value=\"Yes\"  data-radio-field=\"fld_7270164_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_7270164_1_opt1940474\" data-label=\"No\" data-field=\"fld_7270164\" data-ref=\"fld_7270164_1_opt1940474\" class=\"cf-toggle-group-radio fld_7270164_1\" name=\"fld_7270164\" value=\"No\"  data-radio-field=\"fld_7270164_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1476447\" class=\"form-group cf-toggle-switch\" id=\"fld_1476447_1-wrap\">\r\n\t<label id=\"fld_1476447Label\" for=\"fld_1476447_1\" class=\"control-label\">Do you have a close relative with Creutzfeld Jakob Disease?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_1476447_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_1476447\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_1476447Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_1476447_1_opt1940474\" data-label=\"No\" data-field=\"fld_1476447\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_1476447Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_1476447_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_1476447\" data-ref=\"fld_1476447_1_opt1843828\" class=\"cf-toggle-group-radio fld_1476447_1\" name=\"fld_1476447\" value=\"Yes\"  data-radio-field=\"fld_1476447_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_1476447_1_opt1940474\" data-label=\"No\" data-field=\"fld_1476447\" data-ref=\"fld_1476447_1_opt1940474\" class=\"cf-toggle-group-radio fld_1476447_1\" name=\"fld_1476447\" value=\"No\"  data-radio-field=\"fld_1476447_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_8525872\" class=\"form-group cf-toggle-switch\" id=\"fld_8525872_1-wrap\">\r\n\t<label id=\"fld_8525872Label\" for=\"fld_8525872_1\" class=\"control-label\">Do you carry a warning card?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_8525872_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_8525872\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_8525872Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_8525872_1_opt1940474\" data-label=\"No\" data-field=\"fld_8525872\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_8525872Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_8525872_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_8525872\" data-ref=\"fld_8525872_1_opt1843828\" class=\"cf-toggle-group-radio fld_8525872_1\" name=\"fld_8525872\" value=\"Yes\"  data-radio-field=\"fld_8525872_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_8525872_1_opt1940474\" data-label=\"No\" data-field=\"fld_8525872\" data-ref=\"fld_8525872_1_opt1940474\" class=\"cf-toggle-group-radio fld_8525872_1\" name=\"fld_8525872\" value=\"No\"  data-radio-field=\"fld_8525872_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3583065\" class=\"form-group cf-toggle-switch\" id=\"fld_3583065_1-wrap\">\r\n\t<label id=\"fld_3583065Label\" for=\"fld_3583065_1\" class=\"control-label\">Do you smoke? If yes, approximately how many each day?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_3583065_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_3583065\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_3583065Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_3583065_1_opt1940474\" data-label=\"No\" data-field=\"fld_3583065\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_3583065Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_3583065_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_3583065\" data-ref=\"fld_3583065_1_opt1843828\" class=\"cf-toggle-group-radio fld_3583065_1\" name=\"fld_3583065\" value=\"Yes\"  data-radio-field=\"fld_3583065_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_3583065_1_opt1940474\" data-label=\"No\" data-field=\"fld_3583065\" data-ref=\"fld_3583065_1_opt1940474\" class=\"cf-toggle-group-radio fld_3583065_1\" name=\"fld_3583065\" value=\"No\"  data-radio-field=\"fld_3583065_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_1521716\" class=\"form-group cf-toggle-switch\" id=\"fld_1521716_1-wrap\">\r\n\t<label id=\"fld_1521716Label\" for=\"fld_1521716_1\" class=\"control-label\">Do you drink alcohol? If yes, approximately how many units each week?<\/label>\r\n\t<div class=\"\">\r\n\t<div class=\"caldera-config-field init_field_type\" data-type=\"toggle_button\">\n\t\t<div class=\"cf-toggle-group-buttons btn-group\">\n\t\t\t<a id=\"fld_1521716_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_1521716\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"Yes\"  aria-labelledby=\"fld_1521716Label\" title=\"Choose OptionYes\">Yes<\/a><a id=\"fld_1521716_1_opt1940474\" data-label=\"No\" data-field=\"fld_1521716\" data-active=\"btn-success\" data-default=\"btn-default\" class=\"btn btn-default\" data-value=\"No\"  aria-labelledby=\"fld_1521716Label\" title=\"Choose OptionNo\">No<\/a>\t\t\n\t\t<\/div>\n\t\t<div style=\"display:none;\" aria-hidden=\"true\">\n\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_1521716_1_opt1843828\" data-label=\"Yes\" data-field=\"fld_1521716\" data-ref=\"fld_1521716_1_opt1843828\" class=\"cf-toggle-group-radio fld_1521716_1\" name=\"fld_1521716\" value=\"Yes\"  data-radio-field=\"fld_1521716_1\" data-calc-value=\"Yes\" >\n\t\t\t\t\t\t\t\t<input  type=\"radio\" id=\"fld_1521716_1_opt1940474\" data-label=\"No\" data-field=\"fld_1521716\" data-ref=\"fld_1521716_1_opt1940474\" class=\"cf-toggle-group-radio fld_1521716_1\" name=\"fld_1521716\" value=\"No\"  data-radio-field=\"fld_1521716_1\" data-calc-value=\"No\" >\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t<\/div>\r\n<\/div>\r\n<div data-field-wrapper=\"fld_3821376\" class=\"form-group\" id=\"fld_3821376_1-wrap\">\r\n\t<label id=\"fld_3821376Label\" for=\"fld_3821376_1\" class=\"control-label\">Please provide details for any<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_3821376\" value=\"\" data-field=\"fld_3821376\" class=\"form-control\" id=\"fld_3821376_1\" rows=\"4\"    aria-labelledby=\"fld_3821376Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-10\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_7936019\" class=\"form-group\" id=\"fld_7936019_1-wrap\">\r\n\t<label id=\"fld_7936019Label\" for=\"fld_7936019_1\" class=\"control-label\">Please give any other details which your dentist might need to know about, such as self-prescribed medicines (e.g. aspirin) or treatments or medicines that you prefer not to have for religious or personal reasons?<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_7936019\" value=\"\" data-field=\"fld_7936019\" class=\"form-control\" id=\"fld_7936019_1\" rows=\"4\"    aria-labelledby=\"fld_7936019Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5efa0ad158414_1-row-11\"  class=\"row  last_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_7908577\" class=\"form-group\" id=\"fld_7908577_1-wrap\">\r\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_7908577\" id=\"fld_7908577_1\" value=\"Submit Form\" data-field=\"fld_7908577\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_7908577\" id=\"fld_7908577_1_btn\" value=\"\" data-field=\"fld_7908577\"  \/>\n<\/div><\/div><\/form>\r\n<\/div>\r\n\n","protected":false},"excerpt":{"rendered":"<p>MEDICAL HISTORY FORM<\/p>\n","protected":false},"author":2,"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>Medical History Form - Botox Glasgow from \u00a3120 | Dermal Fillers Glasgow \u00a3100 | Clear Braces from \u00a3800<\/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:\/\/bellaradiance.com\/medical-history-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical History Form - Botox Glasgow from \u00a3120 | Dermal Fillers Glasgow \u00a3100 | Clear Braces from \u00a3800\" \/>\n<meta property=\"og:description\" content=\"MEDICAL HISTORY FORM\" \/>\n<meta property=\"og:url\" content=\"https:\/\/bellaradiance.com\/medical-history-form\/\" \/>\n<meta property=\"og:site_name\" content=\"Botox Glasgow from \u00a3120 | Dermal Fillers Glasgow \u00a3100 | Clear Braces from \u00a3800\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bellaradiance.glasgow\/?ref=bookmarks\" \/>\n<meta property=\"og:image\" content=\"https:\/\/bellaradiance.com\/wp-content\/uploads\/2019\/07\/Screenshot-2019-07-10-at-16.15.12.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1617\" \/>\n\t<meta property=\"og:image:height\" content=\"668\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/bellaradiance.com\/medical-history-form\/\",\"url\":\"https:\/\/bellaradiance.com\/medical-history-form\/\",\"name\":\"Medical History Form - 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