{"id":617,"date":"2019-08-18T16:27:31","date_gmt":"2019-08-18T16:27:31","guid":{"rendered":"https:\/\/acupuncturewaran.com\/?page_id=617"},"modified":"2019-08-18T16:27:35","modified_gmt":"2019-08-18T16:27:35","slug":"online-intake-form","status":"publish","type":"page","link":"https:\/\/acupuncturewaran.com\/nl\/online-intake-form","title":{"rendered":"Online Intake Form"},"content":{"rendered":"<div class='fluentform ff-default fluentform_wrapper_1 ffs_default_wrap'><form data-form_id=\"1\" id=\"fluentform_1\" class=\"frm-fluent-form fluent_form_1 ff-el-form-top ff_form_instance_1_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_1_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Patient Intake Form (#1)<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='617' \/><input type=\"hidden\" id=\"_fluentform_1_fluentformnonce\" name=\"_fluentform_1_fluentformnonce\" value=\"802fe9624c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/nl\/wp-json\/wp\/v2\/pages\/617\" \/><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_names_first_name_' id='label_ff_1_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_1_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_names_last_name_' id='label_ff_1_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_1_names_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_input_text_1' id='label_ff_1_input_text_1' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"dd\/mm\/yyyy\" data-name=\"input_text_1\" id=\"ff_1_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Gender\">Gender<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_f7dc26d2dfdae837cfc55610ef4ce488'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Male\"  id='input_radio_11_f7dc26d2dfdae837cfc55610ef4ce488' aria-label='Male' aria-invalid='false' aria-required=true> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_641731eb3841fb70b656ba904d362847'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Female\"  id='input_radio_11_641731eb3841fb70b656ba904d362847' aria-label='Female' aria-invalid='false' aria-required=true> <span>Female<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_d79ba85627f68727b48d2793d1dcaa92'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_11_d79ba85627f68727b48d2793d1dcaa92' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address1\" ><div class='ff-el-input--label'><label aria-label=\"Home Address\">Home Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_1_address1_address_line_1_' id='label_ff_1_address1_address_line_1_' aria-label=\"Address Line 1\">Address Line 1<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address1[address_line_1]\" id=\"ff_1_address1_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_address1_address_line_2_' id='label_ff_1_address1_address_line_2_' aria-label=\"Address Line 2\">Address Line 2<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address1[address_line_2]\" id=\"ff_1_address1_address_line_2_\" class=\"ff-el-form-control\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_1_address1_city_' id='label_ff_1_address1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address1[city]\" id=\"ff_1_address1_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_address1_zip_' id='label_ff_1_address1_zip_' aria-label=\"Postal Code\">Postal Code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address1[zip]\" id=\"ff_1_address1_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_numeric-field' id='label_ff_1_numeric-field' aria-label=\"Home Phone\">Home Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field\" id=\"ff_1_numeric-field\" class=\"ff-el-form-control\" data-name=\"numeric-field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_1_numeric-field_1' id='label_ff_1_numeric-field_1' aria-label=\"Mobile Phone\">Mobile Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_1\" id=\"ff_1_numeric-field_1\" class=\"ff-el-form-control\" data-name=\"numeric-field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_1_email' id='label_ff_1_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_1_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_datetime' id='label_ff_1_datetime' aria-label=\"Appointment Date (If already made)\">Appointment Date (If already made)<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Appointment Date (If already made) Gebruik de pijltjestoetsen om door de datums te navigeren. Druk op enter om een datum te selecteren.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_1_datetime\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/yyyy\" data-name=\"datetime\"  aria-invalid='false' aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_input_text' id='label_ff_1_input_text' aria-label=\"Occupation\">Occupation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"Your current occupation\" data-name=\"input_text\" id=\"ff_1_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names_4\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_names_4_first_name_' id='label_ff_1_names_4_first_name_' >Referred by (If any)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_4[first_name]\" id=\"ff_1_names_4_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div data-type=\"name-element\" data-name=\"names_2\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_names_2_first_name_' id='label_ff_1_names_2_first_name_' >Emergency Contact<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_2[first_name]\" id=\"ff_1_names_2_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_numeric-field_2' id='label_ff_1_numeric-field_2' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_2\" id=\"ff_1_numeric-field_2\" class=\"ff-el-form-control\" data-name=\"numeric-field_2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_1' id='label_ff_1_description_1' aria-label=\"Relationship\">Relationship<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_1\" name=\"description_1\" id=\"ff_1_description_1\" class=\"ff-el-form-control\" rows=\"1\" cols=\"1\" data-name=\"description_1\" ><\/textarea><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-1_1\" ><h3 class='ff-el-section-title'>Medical History<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div data-type=\"name-element\" data-name=\"names_3\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_names_3_first_name_' id='label_ff_1_names_3_first_name_' >Family Physician<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_3[first_name]\" id=\"ff_1_names_3_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_numeric-field_3' id='label_ff_1_numeric-field_3' aria-label=\"Phone\">Phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_1_numeric-field_3\" class=\"ff-el-form-control\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_2' id='label_ff_1_description_2' aria-label=\"Clinic Name\">Clinic Name<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_2\" name=\"description_2\" id=\"ff_1_description_2\" class=\"ff-el-form-control\" rows=\"1\" cols=\"1\" data-name=\"description_2\" ><\/textarea><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Are you currently under physician&#039;s care?\">Are you currently under physician's care?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_0916b0f6eeeadf8524e55ef594c645d1'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_12_0916b0f6eeeadf8524e55ef594c645d1' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_12_e5b8f0d7f7ecdfcb8a4b1e3d3a3321c9'><input  type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_12_e5b8f0d7f7ecdfcb8a4b1e3d3a3321c9' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_3' id='label_ff_1_description_3' aria-label=\"If Yes, for what?\">If Yes, for what?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_3\" name=\"description_3\" id=\"ff_1_description_3\" class=\"ff-el-form-control\" rows=\"2\" cols=\"1\" data-name=\"description_3\" ><\/textarea><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_4' id='label_ff_1_description_4' aria-label=\"List all prescription medications currently taking\">List all prescription medications currently taking<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_4\" name=\"description_4\" id=\"ff_1_description_4\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"description_4\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_5' id='label_ff_1_description_5' aria-label=\"List all non-prescription medications currently taking\">List all non-prescription medications currently taking<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_5\" name=\"description_5\" id=\"ff_1_description_5\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"description_5\" ><\/textarea><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Do you have any allergies?\">Do you have any allergies?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_fbc2498f01dae7969f65a49ac2e0f2e4'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_13_fbc2498f01dae7969f65a49ac2e0f2e4' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_ce52c851ff00db90a4abf8166b727cd7'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_13_ce52c851ff00db90a4abf8166b727cd7' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_6' id='label_ff_1_description_6' aria-label=\"If yes, what?\">If yes, what?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_6\" name=\"description_6\" id=\"ff_1_description_6\" class=\"ff-el-form-control\" rows=\"3\" cols=\"1\" data-name=\"description_6\" ><\/textarea><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_12' id='label_ff_1_description_12' aria-label=\"Past and current medical diagnosis with date\">Past and current medical diagnosis with date<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_12\" name=\"description_12\" id=\"ff_1_description_12\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"description_12\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-1_2\" ><h3 class='ff-el-section-title'>Reason for Your Visit to Our Clinic<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description' id='label_ff_1_description' aria-label=\"Primary Concerns\">Primary Concerns<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description\" name=\"description\" id=\"ff_1_description\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_8\" name=\"description_8\" id=\"ff_1_description_8\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description_8\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_10\" name=\"description_10\" id=\"ff_1_description_10\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description_10\" ><\/textarea><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_1_description_7' id='label_ff_1_description_7' aria-label=\"About how long has it been an issue?\">About how long has it been an issue?<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_7\" name=\"description_7\" id=\"ff_1_description_7\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description_7\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_9\" name=\"description_9\" id=\"ff_1_description_9\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description_9\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_1_description_11\" name=\"description_11\" id=\"ff_1_description_11\" class=\"ff-el-form-control\" rows=\"2\" cols=\"2\" data-name=\"description_11\" ><\/textarea><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-1_3\" ><h3 class='ff-el-section-title'>Women's Health<\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 34%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Any chance of pregnancy?\">Any chance of pregnancy?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_887df9944507bd8be68edfdcf4b490b4'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" 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