{"id":724,"date":"2024-11-22T08:31:48","date_gmt":"2024-11-22T14:31:48","guid":{"rendered":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/?page_id=724"},"modified":"2024-11-22T08:33:44","modified_gmt":"2024-11-22T14:33:44","slug":"uabstv-119-executive-health-physical-registration","status":"publish","type":"page","link":"https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/index.php\/uabstv-119-executive-health-physical-registration\/","title":{"rendered":"UABSTV 119 Executive Health Physical Registration"},"content":{"rendered":"<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&#038;&#038;(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&#038;&#038;t!=i[e].tag||null!=r&#038;&#038;r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_195' style='display:none'><div id='gf_195' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_195' id='gform_195'  action='\/blogs\/greyform\/index.php\/wp-json\/wp\/v2\/pages\/724#gf_195' novalidate>\n        <div id='gf_progressbar_wrapper_195' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>12<\/span> - Patient Information\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_8' style='width:8%;'><span>8%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_195_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_195' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_78\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" >Please complete the form below to begin the appointment scheduling process. Please note the form will take an estimated 10 minutes to complete. \n\n<p>To begin, please <a href=\"https:\/\/uabstvincents.org\/wp-content\/uploads\/sites\/10\/2024\/11\/UAB-St.-Vincents-Nutrition-Consent-Forms.pdf\" target=_blank>click here  review the UAB St. Vincent's Joint Notice of Health Information Privacy Practices >><\/a><\/p> <\/div><fieldset id=\"field_195_3\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >I Accept Acknowledgement of Receipt of Joint Notice of Health Information Privacy Practices.<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_3'>\n\t\t\t<div class='gchoice gchoice_195_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Yes'  id='choice_195_3_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_3_0' id='label_195_3_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='No'  id='choice_195_3_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_3_1' id='label_195_3_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_4\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_195_4'>\n                            \n                            <span id='input_195_4_3_container' class='name_first' >\n                                                    <input type='text' name='input_4.3' id='input_195_4_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_195_4_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_195_4_6_container' class='name_last' >\n                                                    <input type='text' name='input_4.6' id='input_195_4_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_195_4_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_195_6\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_195_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_195_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_195_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_195_6_1' id='input_195_6_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_195_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_195_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_195_6_2' id='input_195_6_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_195_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_195_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_195_6_3' id='input_195_6_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_195_6_4_container' >\n                                        <select name='input_6.4' id='input_195_6_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_195_6_4' id='input_195_6_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_195_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_195_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_195_6_5' id='input_195_6_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_195_6_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_195_7\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_7' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_195_7' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_195_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_195_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_195_7' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_195_8\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_8'>\n\t\t\t<div class='gchoice gchoice_195_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Male'  id='choice_195_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_8_0' id='label_195_8_0'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Female'  id='choice_195_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_8_1' id='label_195_8_1'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_75\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you a post menopausal female NOT currently on hormone replacement therapy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_75'>\n\t\t\t<div class='gchoice gchoice_195_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Yes'  id='choice_195_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_75_0' id='label_195_75_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='No'  id='choice_195_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_75_1' id='label_195_75_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_74\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are your pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_74'>\n\t\t\t<div class='gchoice gchoice_195_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_195_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_74_0' id='label_195_74_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_195_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_74_1' id='label_195_74_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_9\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_9' >Last 4 of Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_9' id='input_195_9' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_195_10\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_10' >Office Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_195_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_195_11\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_11' >Cell Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_195_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_195_13\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Preferred Contact Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_13'>\n\t\t\t<div class='gchoice gchoice_195_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Office'  id='choice_195_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_13_0' id='label_195_13_0'>Office<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Home'  id='choice_195_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_13_1' id='label_195_13_1'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Cell'  id='choice_195_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_13_2' id='label_195_13_2'>Cell<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_14\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_14' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_195_14' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_195_15\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Primary Care Provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_195_15'>\n                            \n                            <span id='input_195_15_3_container' class='name_first' >\n                                                    <input type='text' name='input_15.3' id='input_195_15_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_195_15_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_195_15_6_container' class='name_last' >\n                                                    <input type='text' name='input_15.6' id='input_195_15_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_195_15_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_195_16\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Primary Care Provider Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_195_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_195_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_195_16_1' value=''    aria-required='true'    \/>\n                                        <label for='input_195_16_1' id='input_195_16_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_195_16_2_container' >\n                                        <input type='text' name='input_16.2' id='input_195_16_2' value=''     aria-required='false'   \/>\n                                        <label for='input_195_16_2' id='input_195_16_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_195_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_195_16_3' value=''    aria-required='true'    \/>\n                                    <label for='input_195_16_3' id='input_195_16_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_195_16_4_container' >\n                                        <select name='input_16.4' id='input_195_16_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_195_16_4' id='input_195_16_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_195_16_5_container' >\n                                    <input type='text' name='input_16.5' id='input_195_16_5' value=''    aria-required='true'    \/>\n                                    <label for='input_195_16_5' id='input_195_16_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_16.6' id='input_195_16_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_195_17\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_17' >Primary Care Provider Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_195_17' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_195_18\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_18' >Date of Last Physical<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_195_18' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_195_18_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_195_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_195_18' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_195_19\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Are you interested in choosing a 199 Primary Care Provider?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_19'>\n\t\t\t<div class='gchoice gchoice_195_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_195_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_19_0' id='label_195_19_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_195_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_19_1' id='label_195_19_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_20\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_20' >How did you hear about the Program for Executive Health?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_195_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_195_1' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"2\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"2\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_2' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_21\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Employer Information<\/h3><\/div><div id=\"field_195_22\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_22' >Employer Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_195_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_23\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_23' >Job Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_195_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_195_24\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Employer Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_195_24' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_195_24_1_container' >\n                                        <input type='text' name='input_24.1' id='input_195_24_1' value=''    aria-required='true'    \/>\n                                        <label for='input_195_24_1' id='input_195_24_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_195_24_2_container' >\n                                        <input type='text' name='input_24.2' id='input_195_24_2' value=''     aria-required='false'   \/>\n                                        <label for='input_195_24_2' id='input_195_24_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_195_24_3_container' >\n                                    <input type='text' name='input_24.3' id='input_195_24_3' value=''    aria-required='true'    \/>\n                                    <label for='input_195_24_3' id='input_195_24_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_195_24_4_container' >\n                                        <select name='input_24.4' id='input_195_24_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_195_24_4' id='input_195_24_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_195_24_5_container' >\n                                    <input type='text' name='input_24.5' id='input_195_24_5' value=''    aria-required='true'    \/>\n                                    <label for='input_195_24_5' id='input_195_24_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_24.6' id='input_195_24_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_195_25\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_25' >Employer Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_195_25' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_26' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"1\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"1\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_26' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"3\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"3\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_3' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_27\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Emergency Contact<\/h3><\/div><fieldset id=\"field_195_28\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_195_28'>\n                            \n                            <span id='input_195_28_3_container' class='name_first' >\n                                                    <input type='text' name='input_28.3' id='input_195_28_3' value='' aria-label='First name'   aria-required='true'     \/>\n                                                    <label for='input_195_28_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_195_28_6_container' class='name_last' >\n                                                    <input type='text' name='input_28.6' id='input_195_28_6' value='' aria-label='Last name'   aria-required='true'     \/>\n                                                    <label for='input_195_28_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_195_29\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_29' >Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_195_29' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_195_30\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_30' >Other Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_195_30' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_195_31\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_31' >Relationship to Patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_195_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_32' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"2\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"2\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_32' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"4\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"4\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_4' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_33\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Insurance Data<\/h3><\/div><div id=\"field_195_34\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_34' >Insurance Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_195_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_35\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_35' >Subscriber  Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_195_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_36\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_36' >Group  Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_195_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_37\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_37' >Contract Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_195_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_38\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_38' >Relationship of Patient to Subscriber<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_195_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_195_40\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Insurance Plan Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_195_40' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_195_40_1_container' >\n                                        <input type='text' name='input_40.1' id='input_195_40_1' value=''    aria-required='true'    \/>\n                                        <label for='input_195_40_1' id='input_195_40_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_195_40_2_container' >\n                                        <input type='text' name='input_40.2' id='input_195_40_2' value=''     aria-required='false'   \/>\n                                        <label for='input_195_40_2' id='input_195_40_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_195_40_3_container' >\n                                    <input type='text' name='input_40.3' id='input_195_40_3' value=''    aria-required='true'    \/>\n                                    <label for='input_195_40_3' id='input_195_40_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_195_40_4_container' >\n                                        <select name='input_40.4' id='input_195_40_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_195_40_4' id='input_195_40_4_label' >State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_195_40_5_container' >\n                                    <input type='text' name='input_40.5' id='input_195_40_5' value=''    aria-required='true'    \/>\n                                    <label for='input_195_40_5' id='input_195_40_5_label' >ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_40.6' id='input_195_40_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_195_41\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_41' >Insurance Plan Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_41' id='input_195_41' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_42' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"3\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"3\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_42' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"5\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"5\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_43\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Best Possible Dates for Service<\/h3><\/div><div id=\"field_195_44\" class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_44' >First Option<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_44' id='input_195_44' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_195_44_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_195_44_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_195_44' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_195_46\" class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_46' >Second Option<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_195_46' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_195_46_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_195_46_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_195_46' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_195_45\" class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_45' >Third Option<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_195_45' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_195_45_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_195_45_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_195_45' class='gform_hidden' value='https:\/\/uabforms.hs.uab.edu\/blogs\/greyform\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_54' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"4\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"4\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_54' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"6\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"6\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_6' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_55\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Medical History<\/h3><\/div><div id=\"field_195_49\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_49' >Height<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_195_49' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_50\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_50' >Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_195_50' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_195_59\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please select any of the follow medical conditions that apply to you.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_195_59'><div class='gchoice gchoice_195_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Heart Trouble'  id='choice_195_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_1' id='label_195_59_1'>Heart Trouble<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='High Blood Pressure'  id='choice_195_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_2' id='label_195_59_2'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Heart Murmur'  id='choice_195_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_3' id='label_195_59_3'>Heart Murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Disease of the Arteries'  id='choice_195_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_4' id='label_195_59_4'>Disease of the Arteries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Varicose Veins'  id='choice_195_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_5' id='label_195_59_5'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.6' type='checkbox'  value='Lung Disease'  id='choice_195_59_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_6' id='label_195_59_6'>Lung Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.7' type='checkbox'  value='Emphysema'  id='choice_195_59_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_7' id='label_195_59_7'>Emphysema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.8' type='checkbox'  value='Asthma'  id='choice_195_59_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_8' id='label_195_59_8'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.9' type='checkbox'  value='Kidney Disease'  id='choice_195_59_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_9' id='label_195_59_9'>Kidney Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.11' type='checkbox'  value='Diabetes'  id='choice_195_59_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_11' id='label_195_59_11'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.12' type='checkbox'  value='Thyroid'  id='choice_195_59_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_12' id='label_195_59_12'>Thyroid<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.13' type='checkbox'  value='Liver Disease'  id='choice_195_59_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_13' id='label_195_59_13'>Liver Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.14' type='checkbox'  value='Hepatitis'  id='choice_195_59_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_14' id='label_195_59_14'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.15' type='checkbox'  value='Arthritis'  id='choice_195_59_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_15' id='label_195_59_15'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.16' type='checkbox'  value='Cancer'  id='choice_195_59_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_16' id='label_195_59_16'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_59_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.17' type='checkbox'  value='Other Illness'  id='choice_195_59_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_59_17' id='label_195_59_17'>Other Illness<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_60\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_60' >Other<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_195_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_61' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"5\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"5\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_61' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"7\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"7\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_7' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_7' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_62\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Family History<\/h3><\/div><fieldset id=\"field_195_63\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Has anyone in your family had the following conditions or treatments?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_195_63'><div class='gchoice gchoice_195_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Heart Attacks'  id='choice_195_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_1' id='label_195_63_1'>Heart Attacks<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Heart Operations'  id='choice_195_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_2' id='label_195_63_2'>Heart Operations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.3' type='checkbox'  value='High Blood Pressure'  id='choice_195_63_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_3' id='label_195_63_3'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.4' type='checkbox'  value='High Cholesterol'  id='choice_195_63_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_4' id='label_195_63_4'>High Cholesterol<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.5' type='checkbox'  value='Congenital Heart Disorder'  id='choice_195_63_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_5' id='label_195_63_5'>Congenital Heart Disorder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.6' type='checkbox'  value='Diabetes'  id='choice_195_63_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_6' id='label_195_63_6'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.7' type='checkbox'  value='Stroke'  id='choice_195_63_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_7' id='label_195_63_7'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.8' type='checkbox'  value='Osteoporosis'  id='choice_195_63_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_8' id='label_195_63_8'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.9' type='checkbox'  value='Early Death (if yes, please specify age below)'  id='choice_195_63_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_9' id='label_195_63_9'>Early Death (if yes, please specify age below)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_63_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.11' type='checkbox'  value='Other Illnesses'  id='choice_195_63_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_63_11' id='label_195_63_11'>Other Illnesses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_65\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_65' >Age of Early Death<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_195_65' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_66\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_66' >Other Family Illness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_195_66' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_67' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"6\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"6\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_67' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"8\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"8\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_8' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_8' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_68\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Present Symptoms<\/h3><\/div><fieldset id=\"field_195_69\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please select any of the symptoms you&#039;re presently experiencing<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_195_69'><div class='gchoice gchoice_195_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Chest Pain\/Discomfort'  id='choice_195_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_1' id='label_195_69_1'>Chest Pain\/Discomfort<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.2' type='checkbox'  value='Shortness of Breath'  id='choice_195_69_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_2' id='label_195_69_2'>Shortness of Breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.3' type='checkbox'  value='Heart Palpitations'  id='choice_195_69_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_3' id='label_195_69_3'>Heart Palpitations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.4' type='checkbox'  value='Skipped Heartbeats'  id='choice_195_69_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_4' id='label_195_69_4'>Skipped Heartbeats<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.5' type='checkbox'  value='Cough on Exertion'  id='choice_195_69_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_5' id='label_195_69_5'>Cough on Exertion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.6' type='checkbox'  value='Coughing of Blood'  id='choice_195_69_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_6' id='label_195_69_6'>Coughing of Blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.7' type='checkbox'  value='Dizzy Spells'  id='choice_195_69_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_7' id='label_195_69_7'>Dizzy Spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.8' type='checkbox'  value='Frequent Headaches'  id='choice_195_69_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_8' id='label_195_69_8'>Frequent Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.9' type='checkbox'  value='Frequent Colds'  id='choice_195_69_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_9' id='label_195_69_9'>Frequent Colds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.11' type='checkbox'  value='Back Pain'  id='choice_195_69_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_11' id='label_195_69_11'>Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_69_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.12' type='checkbox'  value='Other Illness'  id='choice_195_69_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_69_12' id='label_195_69_12'>Other Illness<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_70\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_70' >Other Illness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_195_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_76' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"7\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"7\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_76' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"9\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"9\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_9' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_9' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_77\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Please list any current medications below<\/h3><\/div><div id=\"field_195_79\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_79' >Dose\/Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_195_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_82\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_82' >Dose\/Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_195_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_81\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_81' >Dose\/Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_195_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_80\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_80' >Dose\/Frequency<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_195_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_84\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Allergies<\/h3><\/div><div id=\"field_195_85\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_85' >Please List Any Known Allergies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_195_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_86' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"8\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"8\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_86' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"10\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"10\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_10' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_10' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_87\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Orthopaedic Issues<\/h3><\/div><fieldset id=\"field_195_88\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Please select and Orthopaedic issues you may be suffering from<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_195_88'><div class='gchoice gchoice_195_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Neck'  id='choice_195_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_1' id='label_195_88_1'>Neck<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Shoulder'  id='choice_195_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_2' id='label_195_88_2'>Shoulder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='Back'  id='choice_195_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_3' id='label_195_88_3'>Back<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.4' type='checkbox'  value='Elbow'  id='choice_195_88_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_4' id='label_195_88_4'>Elbow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.5' type='checkbox'  value='Hip'  id='choice_195_88_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_5' id='label_195_88_5'>Hip<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.6' type='checkbox'  value='Wrist'  id='choice_195_88_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_6' id='label_195_88_6'>Wrist<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.7' type='checkbox'  value='Knee'  id='choice_195_88_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_7' id='label_195_88_7'>Knee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.8' type='checkbox'  value='Hand'  id='choice_195_88_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_8' id='label_195_88_8'>Hand<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.9' type='checkbox'  value='Ankle'  id='choice_195_88_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_9' id='label_195_88_9'>Ankle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.11' type='checkbox'  value='Foot'  id='choice_195_88_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_11' id='label_195_88_11'>Foot<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.12' type='checkbox'  value='Arthritis'  id='choice_195_88_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_12' id='label_195_88_12'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.13' type='checkbox'  value='Sports Injury'  id='choice_195_88_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_13' id='label_195_88_13'>Sports Injury<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_195_88_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.14' type='checkbox'  value='Further Injury'  id='choice_195_88_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_195_88_14' id='label_195_88_14'>Further Injury<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_89\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_89' >Further Injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_195_89' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_90' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"9\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"9\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_90' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"11\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"11\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_11' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_11' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_91\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Exercise<\/h3><\/div><fieldset id=\"field_195_93\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >How often do you exercise each week?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_93'>\n\t\t\t<div class='gchoice gchoice_195_93_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='0 times per week'  id='choice_195_93_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_0' id='label_195_93_0'>0 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='1 time per week'  id='choice_195_93_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_1' id='label_195_93_1'>1 time per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='2 times per week'  id='choice_195_93_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_2' id='label_195_93_2'>2 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='3 times per week'  id='choice_195_93_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_3' id='label_195_93_3'>3 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='4 times per week'  id='choice_195_93_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_4' id='label_195_93_4'>4 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='5 times per week'  id='choice_195_93_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_5' id='label_195_93_5'>5 times per week<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_93_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_93' type='radio' value='6+ times per week'  id='choice_195_93_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_93_6' id='label_195_93_6'>6+ times per week<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_94\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Cardio<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_94'>\n\t\t\t<div class='gchoice gchoice_195_94_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='0 minutes cardio'  id='choice_195_94_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_0' id='label_195_94_0'>0 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='5 minutes cardio'  id='choice_195_94_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_1' id='label_195_94_1'>5 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='10 minutes cardio'  id='choice_195_94_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_2' id='label_195_94_2'>10 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='15 minutes cardio'  id='choice_195_94_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_3' id='label_195_94_3'>15 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='20 minutes cardio'  id='choice_195_94_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_4' id='label_195_94_4'>20 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='25 minutes cardio'  id='choice_195_94_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_5' id='label_195_94_5'>25 minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value='30+ minutes cardio'  id='choice_195_94_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_6' id='label_195_94_6'>30+ minutes cardio<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_94_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_94' type='radio' value=''  id='choice_195_94_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_94_7' id='label_195_94_7'><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_95\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Weight Training<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_95'>\n\t\t\t<div class='gchoice gchoice_195_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='0 days weight training'  id='choice_195_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_0' id='label_195_95_0'>0 days weight training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='1 day weight training'  id='choice_195_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_1' id='label_195_95_1'>1 day weight training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_95_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='2 days weight training'  id='choice_195_95_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_2' id='label_195_95_2'>2 days weight training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_95_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='3 days weight training'  id='choice_195_95_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_3' id='label_195_95_3'>3 days weight training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_95_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='4 days weight training'  id='choice_195_95_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_4' id='label_195_95_4'>4 days weight training<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_95_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='5+ days weight training'  id='choice_195_95_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_95_5' id='label_195_95_5'>5+ days weight training<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_195_96\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Should you not do Physical Activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_96'>\n\t\t\t<div class='gchoice gchoice_195_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_195_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_96_0' id='label_195_96_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_195_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_96_1' id='label_195_96_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_195_98' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"10\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"10\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_195_98' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_195\").val(\"12\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_195\").val(\"12\");  jQuery(\"#gform_195\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_195_12' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_195_12' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_195_99\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Wellness<\/h3><\/div><div id=\"field_195_100\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_100' >Height at Age 25<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_195_100' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_101\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_101' >Present Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_195_101' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_104\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_104' >Present Weight Maintained (___years___months)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_195_104' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_195_105\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label'  >Satisfied with Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_195_105'>\n\t\t\t<div class='gchoice gchoice_195_105_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='Yes'  id='choice_195_105_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_105_0' id='label_195_105_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_195_105_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_105' type='radio' value='No'  id='choice_195_105_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_195_105_1' id='label_195_105_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_195_106\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_106' >Ideal Weight<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_195_106' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_108\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_108' >Prescribed Diet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_195_108' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_195_109\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_195_109' >How often do you drink caffine? 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