{"id":734,"date":"2023-06-06T13:56:36","date_gmt":"2023-06-06T13:56:36","guid":{"rendered":"https:\/\/premieralternativemeds.com\/?page_id=734"},"modified":"2023-06-06T13:57:04","modified_gmt":"2023-06-06T13:57:04","slug":"health-form","status":"publish","type":"page","link":"https:\/\/premieralternativemeds.com\/?page_id=734","title":{"rendered":"Health Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; theme_builder_area=&#8221;post_content&#8221; _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221;][et_pb_row _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_column _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; type=&#8221;4_4&#8243; theme_builder_area=&#8221;post_content&#8221;][et_pb_code _builder_version=&#8221;4.21.0&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;]<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),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),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Customer Information Form<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F734#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_18\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><legend class='gfield_label gform-field-label' >Today&#039;s Date<\/legend><div id='input_5_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_7_1_container'><select name='input_7[]' id='input_5_7_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_7_2_container'><select name='input_7[]' id='input_5_7_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_7_3_container'><select name='input_7[]' id='input_5_7_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_5_15\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><div class=\"frm_message\">\n\nEnsuring that our patients' information is safe and secure is one of our top priorities. This form is SHA-256 with RSA Encrypted.\n\n<\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><h4>Patient Authorization for Delivery of Medications<\/h4><\/div><fieldset id=\"field_5_27\" class=\"gfield gfield--type-name gfield--width-half hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_27'>\n                            \n                            <span id='input_5_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_5_27_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_27_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_89\" class=\"gfield gfield--type-name gfield--width-half hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_89'>\n                            \n                            \n                            \n                            <span id='input_5_89_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.6' id='input_5_89_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_89_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_14\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><p>hereby authorize the clinic\u2019s staff on duty to act on my behalf to accept medication delivery from the clinic\u2019s dispensing physician and deliver my medications and refills to me as prescribed by my physician.<br>\n\n<br>I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. If your state is not licensed by any of the compounding pharmacies, we are allowed to sign for the order and send it to the patient. Any orders delivered damaged or incomplete must be reported to Premier Alternative Medicine, referred to as PAM, within 24 hours of delivery, and the pictures of damaged package\/product must be sent to info@premieralternativemeds.com.<br>\n\n<br>PAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the customer's address, it is up to the customer to report any missing or stolen packages to PAM within 24 hours of the delivery date.<br>\n\n<br>Any packages returned for an INCOMPLETE\/ INCORRECT address can be shipped again at the patient's expense.<br>\n\n<br><b>No Guarantee of Services<\/b>\n\n<br>We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign-up process and physician\u2019s examination. At the physician\u2019s discretion only, you will be provided medications and\/or services during your program at PAM.<br>\n\n<br>PAM requires you to have an annual consultation with our provider, and annual lab work is done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time.<br>\n\n<br><b>No Refund Policy<\/b>\n\n<br>*PAM reserves the right to have NO RETURN and NO REFUND policy.<\/p><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_1.1' id='input_5_1_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_1_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_1.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_1.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_19' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_23\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" >Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA only for prescribed deficiencies. Using it for other symptoms or problems is considered \u201coff-label\u201d use, and the liability is on the patient, not the doctor. When hormone levels are brought back to \u201cnormal\u201d for your age, there is much evidence that your overall health benefits. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment.<br>\n\n<br>Current medical thinking is always changing, so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest thinking is. Please read the following and sign: I have discussed the reason for taking female sex hormones with my doctor and understand why he\/she is prescribing them and the risks associated with taking hormones, including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different risks if I take any HRT medication.<br>\n\n<br>I have discussed this risk and the reasons for taking them with my doctor. I understand that my doctor will do everything he\/she knows to do to decrease and minimize the risks of HRT but that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my doctor prescribe them for me.<\/div><div id=\"field_5_24\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><label class='gfield_label gform-field-label' for='input_5_24'>Referred By<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_24' id='input_5_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><legend class='gfield_label gform-field-label' >New to HRT\/TRT, or transferring?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_25'>\n\t\t\t<div class='gchoice gchoice_5_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='New Patient'  id='choice_5_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_0' id='label_5_25_0' class='gform-field-label gform-field-label--type-inline'>New Patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Transferring'  id='choice_5_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>Transferring<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>Who are you transferring from?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_5_28' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_28_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_28' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/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_5_22' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_22' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_31\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" >General information about the participant:<\/div><fieldset id=\"field_5_32\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\" ><legend class='gfield_label gform-field-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 ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_32'>\n                            \n                            <span id='input_5_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.3' id='input_5_32_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_32_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.6' id='input_5_32_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_32_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_33\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-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 gform-grid-row' id='input_5_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_33_1_container' >\n                                        <input type='text' name='input_33.1' id='input_5_33_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_33_1' id='input_5_33_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_33_2_container' >\n                                        <input type='text' name='input_33.2' id='input_5_33_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_33_2' id='input_5_33_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_33_3_container' >\n                                    <input type='text' name='input_33.3' id='input_5_33_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_33_3' id='input_5_33_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_33_4_container' >\n                                        <input type='text' name='input_33.4' id='input_5_33_4' value=''      aria-required='true'    \/>\n                                        <label for='input_5_33_4' id='input_5_33_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_33_5_container' >\n                                    <input type='text' name='input_33.5' id='input_5_33_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_33_5' id='input_5_33_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_33.6' id='input_5_33_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_34\" class=\"gfield gfield--type-phone gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><label class='gfield_label gform-field-label' for='input_5_34'>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_34' id='input_5_34' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>Secondary Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_5_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><legend class='gfield_label gform-field-label' >Is it also OK to text you?<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_5_35'>\n\t\t\t<div class='gchoice gchoice_5_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_5_35_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_35\"   \/>\n\t\t\t\t\t<label for='choice_5_35_0' id='label_5_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_5_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_35'>No worries, we don't spam! <\/div><\/fieldset><div id=\"field_5_37\" class=\"gfield gfield--type-email gfield--width-full hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\" ><label class='gfield_label gform-field-label' for='input_5_37'>Email<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_37' id='input_5_37' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" ><label class='gfield_label gform-field-label' for='input_5_47'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_5_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Married' >Married<\/option><option value='Divorced' >Divorced<\/option><option value='Single' >Single<\/option><option value='Widowed' >Widowed<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><label class='gfield_label gform-field-label' for='input_5_48'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_5_48' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_21' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_39\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" >Please provide information about any current primary care provider below.<\/div><fieldset id=\"field_5_40\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doctor\/Other Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_40'>\n                            \n                            <span id='input_5_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.3' id='input_5_40_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_40_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.6' id='input_5_40_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_40_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Physician Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_41' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_41_1_container' >\n                                        <input type='text' name='input_41.1' id='input_5_41_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_41_1' id='input_5_41_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_41_2_container' >\n                                        <input type='text' name='input_41.2' id='input_5_41_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_41_2' id='input_5_41_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_41_3_container' >\n                                    <input type='text' name='input_41.3' id='input_5_41_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_41_3' id='input_5_41_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_41_4_container' >\n                                        <input type='text' name='input_41.4' id='input_5_41_4' value=''      aria-required='false'    \/>\n                                        <label for='input_5_41_4' id='input_5_41_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_41_5_container' >\n                                    <input type='text' name='input_41.5' id='input_5_41_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_41_5' id='input_5_41_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_41.6' id='input_5_41_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Physician Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_5_42' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><legend class='gfield_label gform-field-label' >May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_43'>\n\t\t\t<div class='gchoice gchoice_5_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_5_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_0' id='label_5_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_5_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_1' id='label_5_43_1' class='gform-field-label gform-field-label--type-inline'>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_5_46' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_46' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_5' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><legend class='gfield_label gform-field-label' >What is (are) your purpose (s) for participation in this HRT Program?<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_5_51'>\n\t\t\t<div class='gchoice gchoice_5_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='To determine my current level of health and to receive recommendations for an HRT program.'  id='choice_5_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_0' id='label_5_51_0' class='gform-field-label gform-field-label--type-inline'>To determine my current level of health and to receive recommendations for an HRT program.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Other (please explain below)'  id='choice_5_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_1' id='label_5_51_1' class='gform-field-label gform-field-label--type-inline'>Other (please explain below)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Explain what is (are) your purpose (s) for participation in this HRT Program?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_5_53' class='textarea small'    placeholder='Use this area to explain other reasons for participation in this HRT program.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Present Medical History<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_55'><div class='gchoice gchoice_5_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Has a doctor ever said your blood pressure was too high'  id='choice_5_55_1'   aria-describedby=\"gfield_description_5_55\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever said your blood pressure was too high<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Do you ever have pain in your chest or heart'  id='choice_5_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_2' id='label_5_55_2' class='gform-field-label gform-field-label--type-inline'>Do you ever have pain in your chest or heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Are you often bothered by a thumping of the heart'  id='choice_5_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_3' id='label_5_55_3' class='gform-field-label gform-field-label--type-inline'>Are you often bothered by a thumping of the heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='Does your heart often race'  id='choice_5_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_4' id='label_5_55_4' class='gform-field-label gform-field-label--type-inline'>Does your heart often race<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='Extra heartbeats or skipped beats'  id='choice_5_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_5' id='label_5_55_5' class='gform-field-label gform-field-label--type-inline'>Extra heartbeats or skipped beats<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Are your ankles often badly swollen'  id='choice_5_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_6' id='label_5_55_6' class='gform-field-label gform-field-label--type-inline'>Are your ankles often badly swollen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.7' type='checkbox'  value='Do cold hands or feet trouble you even in hot weather'  id='choice_5_55_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_7' id='label_5_55_7' class='gform-field-label gform-field-label--type-inline'>Do cold hands or feet trouble you even in hot weather<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.8' type='checkbox'  value='Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary'  id='choice_5_55_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_8' id='label_5_55_8' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.9' type='checkbox'  value='Do you suffer from frequent cramps in your legs'  id='choice_5_55_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_9' id='label_5_55_9' class='gform-field-label gform-field-label--type-inline'>Do you suffer from frequent cramps in your legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.11' type='checkbox'  value='Do you often have difficulty breathing'  id='choice_5_55_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_11' id='label_5_55_11' class='gform-field-label gform-field-label--type-inline'>Do you often have difficulty breathing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.12' type='checkbox'  value='Do you get out of breath long before anyone else'  id='choice_5_55_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_12' id='label_5_55_12' class='gform-field-label gform-field-label--type-inline'>Do you get out of breath long before anyone else<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.13' type='checkbox'  value='Do you sometimes get out of breath when sitting still or sleeping'  id='choice_5_55_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_13' id='label_5_55_13' class='gform-field-label gform-field-label--type-inline'>Do you sometimes get out of breath when sitting still or sleeping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.14' type='checkbox'  value='Has a doctor ever told you your cholesterol level was high'  id='choice_5_55_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_14' id='label_5_55_14' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you your cholesterol level was high<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.15' type='checkbox'  value='Has a doctor ever told you that you have an abdominal aortic aneurysm'  id='choice_5_55_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_15' id='label_5_55_15' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you that you have an abdominal aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.16' type='checkbox'  value='Has a doctor ever told you that you have critical aortic stenosis'  id='choice_5_55_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_16' id='label_5_55_16' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you that you have critical aortic stenosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_55'>Check those questions to which you answer yes (leave the others blank).\n<\/div><\/fieldset><fieldset id=\"field_5_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you now have or have you recently experienced:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_57'><div class='gchoice gchoice_5_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Chronic, recurrent or morning cough'  id='choice_5_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_1' id='label_5_57_1' class='gform-field-label gform-field-label--type-inline'>Chronic, recurrent or morning cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Episode of coughing up blood'  id='choice_5_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_2' id='label_5_57_2' class='gform-field-label gform-field-label--type-inline'>Episode of coughing up blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Increased anxiety or depression'  id='choice_5_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_3' id='label_5_57_3' class='gform-field-label gform-field-label--type-inline'>Increased anxiety or depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Problems with recurrent fatigue, trouble sleeping or increased irritability'  id='choice_5_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_4' id='label_5_57_4' class='gform-field-label gform-field-label--type-inline'>Problems with recurrent fatigue, trouble sleeping or increased irritability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Migraine or recurrent headaches'  id='choice_5_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_5' id='label_5_57_5' class='gform-field-label gform-field-label--type-inline'>Migraine or recurrent headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Swollen or painful knees or ankles'  id='choice_5_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_6' id='label_5_57_6' class='gform-field-label gform-field-label--type-inline'>Swollen or painful knees or ankles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Swollen, stiff or painful joints'  id='choice_5_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_7' id='label_5_57_7' class='gform-field-label gform-field-label--type-inline'>Swollen, stiff or painful joints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='Pain in your legs after walking short distances'  id='choice_5_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_8' id='label_5_57_8' class='gform-field-label gform-field-label--type-inline'>Pain in your legs after walking short distances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.9' type='checkbox'  value='Foot problems'  id='choice_5_57_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_9' id='label_5_57_9' class='gform-field-label gform-field-label--type-inline'>Foot problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.11' type='checkbox'  value='Back problems'  id='choice_5_57_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_11' id='label_5_57_11' class='gform-field-label gform-field-label--type-inline'>Back problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.12' type='checkbox'  value='Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea'  id='choice_5_57_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_12' id='label_5_57_12' class='gform-field-label gform-field-label--type-inline'>Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.13' type='checkbox'  value='Significant vision or hearing problems'  id='choice_5_57_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_13' id='label_5_57_13' class='gform-field-label gform-field-label--type-inline'>Significant vision or hearing problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.14' type='checkbox'  value='Recent change in a wart or a mole'  id='choice_5_57_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_14' id='label_5_57_14' class='gform-field-label gform-field-label--type-inline'>Recent change in a wart or a mole<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.15' type='checkbox'  value='Glaucoma or increased pressure in the eyes'  id='choice_5_57_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_15' id='label_5_57_15' class='gform-field-label gform-field-label--type-inline'>Glaucoma or increased pressure in the eyes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.16' type='checkbox'  value='Exposure to loud noises for long periods'  id='choice_5_57_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_16' id='label_5_57_16' class='gform-field-label gform-field-label--type-inline'>Exposure to loud noises for long periods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.17' type='checkbox'  value='An infection such as pneumonia accompanied by a fever'  id='choice_5_57_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_17' id='label_5_57_17' class='gform-field-label gform-field-label--type-inline'>An infection such as pneumonia accompanied by a fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.18' type='checkbox'  value='Significant unexplained weight loss'  id='choice_5_57_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_18' id='label_5_57_18' class='gform-field-label gform-field-label--type-inline'>Significant unexplained weight loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.19' type='checkbox'  value='A fever, which can cause dehydration and rapid heartbeat'  id='choice_5_57_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_19' id='label_5_57_19' class='gform-field-label gform-field-label--type-inline'>A fever, which can cause dehydration and rapid heartbeat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.21' type='checkbox'  value='A deep vein thrombosis (blood clot)'  id='choice_5_57_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_21' id='label_5_57_21' class='gform-field-label gform-field-label--type-inline'>A deep vein thrombosis (blood clot)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.22' type='checkbox'  value='A hernia that is causing symptoms'  id='choice_5_57_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_22' id='label_5_57_22' class='gform-field-label gform-field-label--type-inline'>A hernia that is causing symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.23' type='checkbox'  value='Foot or ankle sores that won&#039;t heal'  id='choice_5_57_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_23' id='label_5_57_23' class='gform-field-label gform-field-label--type-inline'>Foot or ankle sores that won't heal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.24' type='checkbox'  value='Persistent pain or problems walking after you have fallen'  id='choice_5_57_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_24' id='label_5_57_24' class='gform-field-label gform-field-label--type-inline'>Persistent pain or problems walking after you have fallen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.25' type='checkbox'  value='Eye conditions such as bleeding in the retina or detached retina'  id='choice_5_57_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_25' id='label_5_57_25' class='gform-field-label gform-field-label--type-inline'>Eye conditions such as bleeding in the retina or detached retina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.26' type='checkbox'  value='Cataract or lens transplant'  id='choice_5_57_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_26' id='label_5_57_26' class='gform-field-label gform-field-label--type-inline'>Cataract or lens transplant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.27' type='checkbox'  value='Laser treatment or other eye surgery'  id='choice_5_57_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_27' id='label_5_57_27' class='gform-field-label gform-field-label--type-inline'>Laser treatment or other eye surgery<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_88\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\" ><label class='gfield_label gform-field-label' for='input_5_88'>Additional Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_5_88' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_59' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_6' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_60'><div class='gchoice gchoice_5_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Menstrual period problems'  id='choice_5_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_1' id='label_5_60_1' class='gform-field-label gform-field-label--type-inline'>Menstrual period problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Significant childbirth - related problems'  id='choice_5_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_2' id='label_5_60_2' class='gform-field-label gform-field-label--type-inline'>Significant childbirth - related problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Urine loss when you cough, sneeze or laugh'  id='choice_5_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_3' id='label_5_60_3' class='gform-field-label gform-field-label--type-inline'>Urine loss when you cough, sneeze or laugh<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_61\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><label class='gfield_label gform-field-label' for='input_5_61'>Date of last pelvic exam\/pap smear<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_5_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_61_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_61_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_61' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><label class='gfield_label gform-field-label' for='input_5_62'>Additional Comments regarding female specific sexual based health history<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_5_62' class='textarea small'  aria-describedby=\"gfield_description_5_62\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_5_62'>Please use this area to add additional comments regarding female specific sexual based health history.<\/div><\/div><fieldset id=\"field_5_63\" class=\"gfield gfield--type-list gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List any prescription medications you are now taking<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Prescription Medicines<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_63_cell1 gform-grid-col' data-label='Prescription Medicines'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_63\" aria-label='Prescription Medicines, Row 1' data-aria-label-template='Prescription Medicines, Row {0}' type='text' name='input_63[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 8)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 8)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_63'>Please use the plus button to the right to add all medicine you're currently taking.<\/div><\/fieldset><fieldset id=\"field_5_64\" class=\"gfield gfield--type-list gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List any self-prescribed medications, dietary supplements, or vitamins you are now taking<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Other supplements<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_64_cell1 gform-grid-col' data-label='Other supplements'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_64\" aria-label='Other supplements, Row 1' data-aria-label-template='Other supplements, Row {0}' type='text' name='input_64[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 8)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 8)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_64'>Please use the plus button to the right to add all medicine you're currently taking.<\/div><\/fieldset><div id=\"field_5_65\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><label class='gfield_label gform-field-label' for='input_5_65'>Date of last complete physical examination<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_65' id='input_5_65' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_65_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_65_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_65' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><legend class='gfield_label gform-field-label' >Outcome of last physical exam<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_66'>\n\t\t\t<div class='gchoice gchoice_5_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Normal'  id='choice_5_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Abnormal'  id='choice_5_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Never'  id='choice_5_66_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_2' id='label_5_66_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_66_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_3' id='label_5_66_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_67\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><label class='gfield_label gform-field-label' for='input_5_67'>Date of last chest X-ray<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_67' id='input_5_67' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_67_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_67_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_67' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_68\" ><legend class='gfield_label gform-field-label' >Outcome of last chest X-Ray<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_68'>\n\t\t\t<div class='gchoice gchoice_5_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Normal'  id='choice_5_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_0' id='label_5_68_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Abnormal'  id='choice_5_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_1' id='label_5_68_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Never'  id='choice_5_68_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_2' id='label_5_68_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_68_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_3' id='label_5_68_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_69\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\" ><label class='gfield_label gform-field-label' for='input_5_69'>Date of last electrocardiogram (EKG or ECG)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_69' id='input_5_69' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_69_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_69_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_69' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_70\" ><legend class='gfield_label gform-field-label' >Outcome of last (EKG or ECG)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_70'>\n\t\t\t<div class='gchoice gchoice_5_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Normal'  id='choice_5_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_0' id='label_5_70_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Abnormal'  id='choice_5_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_1' id='label_5_70_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Never'  id='choice_5_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_2' id='label_5_70_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_70_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_3' id='label_5_70_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_71\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_71\" ><label class='gfield_label gform-field-label' for='input_5_71'>Date of last dental checkup<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_5_71' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_71_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_71_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_71' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\" ><legend class='gfield_label gform-field-label' >Outcome of last dental checkup<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_72'>\n\t\t\t<div class='gchoice gchoice_5_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Normal'  id='choice_5_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_0' id='label_5_72_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Abnormal'  id='choice_5_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_1' id='label_5_72_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Never'  id='choice_5_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_2' id='label_5_72_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_72_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_3' id='label_5_72_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/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_5_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_50' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"7\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"7\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_7' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_74\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Past Medical History<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_74'><div class='gchoice gchoice_5_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Rheumatic Fever'  id='choice_5_74_1'   aria-describedby=\"gfield_description_5_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Heart murmur'  id='choice_5_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_2' id='label_5_74_2' class='gform-field-label gform-field-label--type-inline'>Heart murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Diseases of the arteries'  id='choice_5_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_3' id='label_5_74_3' class='gform-field-label gform-field-label--type-inline'>Diseases of the arteries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Varicose veins'  id='choice_5_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_4' id='label_5_74_4' class='gform-field-label gform-field-label--type-inline'>Varicose veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='Arthritis of legs or arms'  id='choice_5_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_5' id='label_5_74_5' class='gform-field-label gform-field-label--type-inline'>Arthritis of legs or arms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Diabetes or abnormal blood-sugar tests'  id='choice_5_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_6' id='label_5_74_6' class='gform-field-label gform-field-label--type-inline'>Diabetes or abnormal blood-sugar tests<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.7' type='checkbox'  value='Phlebitis (inflammation of a vein)'  id='choice_5_74_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_7' id='label_5_74_7' class='gform-field-label gform-field-label--type-inline'>Phlebitis (inflammation of a vein)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.8' type='checkbox'  value='Dizziness or fainting spells'  id='choice_5_74_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_8' id='label_5_74_8' class='gform-field-label gform-field-label--type-inline'>Dizziness or fainting spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.9' type='checkbox'  value='Epilepsy or seizures'  id='choice_5_74_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_9' id='label_5_74_9' class='gform-field-label gform-field-label--type-inline'>Epilepsy or seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.11' type='checkbox'  value='Stroke'  id='choice_5_74_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_11' id='label_5_74_11' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.12' type='checkbox'  value='Diphtheria'  id='choice_5_74_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_12' id='label_5_74_12' class='gform-field-label gform-field-label--type-inline'>Diphtheria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.13' type='checkbox'  value='Scarlet Fever'  id='choice_5_74_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_13' id='label_5_74_13' class='gform-field-label gform-field-label--type-inline'>Scarlet Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.14' type='checkbox'  value='Infectious mononucleosis'  id='choice_5_74_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_14' id='label_5_74_14' class='gform-field-label gform-field-label--type-inline'>Infectious mononucleosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.15' type='checkbox'  value='Nervous or emotional problems'  id='choice_5_74_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_15' id='label_5_74_15' class='gform-field-label gform-field-label--type-inline'>Nervous or emotional problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.16' type='checkbox'  value='Anemia'  id='choice_5_74_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_16' id='label_5_74_16' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.17' type='checkbox'  value='Thyroid problems'  id='choice_5_74_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_17' id='label_5_74_17' class='gform-field-label gform-field-label--type-inline'>Thyroid problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.18' type='checkbox'  value='Pneumonia'  id='choice_5_74_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_18' id='label_5_74_18' class='gform-field-label gform-field-label--type-inline'>Pneumonia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.19' type='checkbox'  value='Bronchitis'  id='choice_5_74_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_19' id='label_5_74_19' class='gform-field-label gform-field-label--type-inline'>Bronchitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.21' type='checkbox'  value='Asthma'  id='choice_5_74_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_21' id='label_5_74_21' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.22' type='checkbox'  value='Abnormal chest X-ray'  id='choice_5_74_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_22' id='label_5_74_22' class='gform-field-label gform-field-label--type-inline'>Abnormal chest X-ray<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.23' type='checkbox'  value='Other lung disease'  id='choice_5_74_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_23' id='label_5_74_23' class='gform-field-label gform-field-label--type-inline'>Other lung disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.24' type='checkbox'  value='Injuries to back, arms, legs or joint'  id='choice_5_74_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_24' id='label_5_74_24' class='gform-field-label gform-field-label--type-inline'>Injuries to back, arms, legs or joint<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.25' type='checkbox'  value='Broken bones'  id='choice_5_74_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_25' id='label_5_74_25' class='gform-field-label gform-field-label--type-inline'>Broken bones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.26' type='checkbox'  value='Jaundice or gallbladder problems'  id='choice_5_74_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_26' id='label_5_74_26' class='gform-field-label gform-field-label--type-inline'>Jaundice or gallbladder problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.27' type='checkbox'  value='Heart attack (if yes, enter years below)'  id='choice_5_74_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_27' id='label_5_74_27' class='gform-field-label gform-field-label--type-inline'>Heart attack (if yes, enter years below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_74'>Check those questions to which your answer is yes (leave others blank).\n<\/div><\/fieldset><div id=\"field_5_75\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\" ><label class='gfield_label gform-field-label' for='input_5_75'>How many years ago did you have heart attack?<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_5_75' type='text' value='' class='small'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_76\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\" ><label class='gfield_label gform-field-label' for='input_5_76'>Additional comments about past medical history<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_76' id='input_5_76' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_77' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_77' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"8\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"8\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_8' class='gform_page' data-js='page-field-id-77' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_79\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\" ><\/div><fieldset id=\"field_5_78\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Low Testosterone symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_78'><div class='gchoice gchoice_5_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Sexual dysfunction'  id='choice_5_78_1'   aria-describedby=\"gfield_description_5_78\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>Sexual dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Body fatigue or weakness'  id='choice_5_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_2' id='label_5_78_2' class='gform-field-label gform-field-label--type-inline'>Body fatigue or weakness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Depression or anxiety'  id='choice_5_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_3' id='label_5_78_3' class='gform-field-label gform-field-label--type-inline'>Depression or anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Increased body fat'  id='choice_5_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_4' id='label_5_78_4' class='gform-field-label gform-field-label--type-inline'>Increased body fat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Increased irritability'  id='choice_5_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_5' id='label_5_78_5' class='gform-field-label gform-field-label--type-inline'>Increased irritability<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_78'>Check box that pertains to you.<\/div><\/fieldset><fieldset id=\"field_5_80\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sexual dysfunction symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_80'><div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.1' type='checkbox'  value='Inability to get an erection'  id='choice_5_80_1'   aria-describedby=\"gfield_description_5_80\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>Inability to get an erection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_80_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.2' type='checkbox'  value='Difficulty maintaining an erection'  id='choice_5_80_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_2' id='label_5_80_2' class='gform-field-label gform-field-label--type-inline'>Difficulty maintaining an erection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_80_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.3' type='checkbox'  value='Reduced sex drive'  id='choice_5_80_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_3' id='label_5_80_3' class='gform-field-label gform-field-label--type-inline'>Reduced sex drive<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_80'>Check box that pertains to you.<\/div><\/fieldset><fieldset id=\"field_5_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anabolic necessity symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_81'><div class='gchoice gchoice_5_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Have you lost weight or muscle tissue from surgery, trauma, or depression'  id='choice_5_81_1'   aria-describedby=\"gfield_description_5_81\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>Have you lost weight or muscle tissue from surgery, trauma, or depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_81_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.2' type='checkbox'  value='Do 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class='gchoice gchoice_5_81_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.5' type='checkbox'  value='Do you suffer muscle soreness and fatigue'  id='choice_5_81_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_5' id='label_5_81_5' class='gform-field-label gform-field-label--type-inline'>Do you suffer muscle soreness and fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_81'>Check the box that pertains to you.\n<\/div><\/fieldset><fieldset id=\"field_5_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Low HGH symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_82'><div class='gchoice 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method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F734#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_18\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_18\" ><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_7\" ><legend class='gfield_label gform-field-label' >Today&#039;s Date<\/legend><div id='input_5_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_5_7_1_container'><select name='input_7[]' id='input_5_7_1'   aria-required='false'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_5_7_2_container'><select name='input_7[]' id='input_5_7_2'   aria-required='false'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_5_7_3_container'><select name='input_7[]' id='input_5_7_3'   aria-required='false'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_5_15\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_15\" ><div class=\"frm_message\">\n\nEnsuring that our patients' information is safe and secure is one of our top priorities. This form is SHA-256 with RSA Encrypted.\n\n<\/div><\/div><div id=\"field_5_16\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_16\" ><h4>Patient Authorization for Delivery of Medications<\/h4><\/div><fieldset id=\"field_5_27\" class=\"gfield gfield--type-name gfield--width-half hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_27'>\n                            \n                            <span id='input_5_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_5_27_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_27_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_89\" class=\"gfield gfield--type-name gfield--width-half hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_89\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_5_89'>\n                            \n                            \n                            \n                            <span id='input_5_89_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_89.6' id='input_5_89_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_89_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_14\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_14\" ><p>hereby authorize the clinic\u2019s staff on duty to act on my behalf to accept medication delivery from the clinic\u2019s dispensing physician and deliver my medications and refills to me as prescribed by my physician.<br>\n\n<br>I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. If your state is not licensed by any of the compounding pharmacies, we are allowed to sign for the order and send it to the patient. Any orders delivered damaged or incomplete must be reported to Premier Alternative Medicine, referred to as PAM, within 24 hours of delivery, and the pictures of damaged package\/product must be sent to info@premieralternativemeds.com.<br>\n\n<br>PAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the customer's address, it is up to the customer to report any missing or stolen packages to PAM within 24 hours of the delivery date.<br>\n\n<br>Any packages returned for an INCOMPLETE\/ INCORRECT address can be shipped again at the patient's expense.<br>\n\n<br><b>No Guarantee of Services<\/b>\n\n<br>We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign-up process and physician\u2019s examination. At the physician\u2019s discretion only, you will be provided medications and\/or services during your program at PAM.<br>\n\n<br>PAM requires you to have an annual consultation with our provider, and annual lab work is done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time.<br>\n\n<br><b>No Refund Policy<\/b>\n\n<br>*PAM reserves the right to have NO RETURN and NO REFUND policy.<\/p><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend><div class='ginput_container ginput_container_consent'><input name='input_1.1' id='input_5_1_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_1_1' >I agree to the privacy policy.<\/label><input type='hidden' name='input_1.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input type='hidden' name='input_1.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_19' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-19' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_23\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_23\" >Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA only for prescribed deficiencies. Using it for other symptoms or problems is considered \u201coff-label\u201d use, and the liability is on the patient, not the doctor. When hormone levels are brought back to \u201cnormal\u201d for your age, there is much evidence that your overall health benefits. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment.<br>\n\n<br>Current medical thinking is always changing, so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest thinking is. Please read the following and sign: I have discussed the reason for taking female sex hormones with my doctor and understand why he\/she is prescribing them and the risks associated with taking hormones, including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different risks if I take any HRT medication.<br>\n\n<br>I have discussed this risk and the reasons for taking them with my doctor. I understand that my doctor will do everything he\/she knows to do to decrease and minimize the risks of HRT but that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my doctor prescribe them for me.<\/div><div id=\"field_5_24\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_24\" ><label class='gfield_label gform-field-label' for='input_5_24'>Referred By<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_24' id='input_5_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_5_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_25\" ><legend class='gfield_label gform-field-label' >New to HRT\/TRT, or transferring?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_25'>\n\t\t\t<div class='gchoice gchoice_5_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='New Patient'  id='choice_5_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_0' id='label_5_25_0' class='gform-field-label gform-field-label--type-inline'>New Patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Transferring'  id='choice_5_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>Transferring<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_26\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_26\" ><label class='gfield_label gform-field-label' for='input_5_26'>Who are you transferring from?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_5_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_28\" ><label class='gfield_label gform-field-label' for='input_5_28'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_5_28' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_28_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_28' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/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_5_22' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"1\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_22' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_31\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_31\" >General information about the participant:<\/div><fieldset id=\"field_5_32\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_32\" ><legend class='gfield_label gform-field-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 ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_32'>\n                            \n                            <span id='input_5_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.3' id='input_5_32_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_32_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_32.6' id='input_5_32_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_32_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_33\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_33\" ><legend class='gfield_label gform-field-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 gform-grid-row' id='input_5_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_33_1_container' >\n                                        <input type='text' name='input_33.1' id='input_5_33_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_33_1' id='input_5_33_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_33_2_container' >\n                                        <input type='text' name='input_33.2' id='input_5_33_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_33_2' id='input_5_33_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_33_3_container' >\n                                    <input type='text' name='input_33.3' id='input_5_33_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_33_3' id='input_5_33_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_33_4_container' >\n                                        <input type='text' name='input_33.4' id='input_5_33_4' value=''      aria-required='true'    \/>\n                                        <label for='input_5_33_4' id='input_5_33_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_33_5_container' >\n                                    <input type='text' name='input_33.5' id='input_5_33_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_33_5' id='input_5_33_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_33.6' id='input_5_33_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_34\" class=\"gfield gfield--type-phone gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_34\" ><label class='gfield_label gform-field-label' for='input_5_34'>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_34' id='input_5_34' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_36\" ><label class='gfield_label gform-field-label' for='input_5_36'>Secondary Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_5_36' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_35\" ><legend class='gfield_label gform-field-label' >Is it also OK to text you?<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_5_35'>\n\t\t\t<div class='gchoice gchoice_5_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_5_35_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_5_35\"   \/>\n\t\t\t\t\t<label for='choice_5_35_0' id='label_5_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_5_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_35_1' id='label_5_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_35'>No worries, we don't spam! <\/div><\/fieldset><div id=\"field_5_37\" class=\"gfield gfield--type-email gfield--width-full hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_37\" ><label class='gfield_label gform-field-label' for='input_5_37'>Email<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_37' id='input_5_37' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_47\" ><label class='gfield_label gform-field-label' for='input_5_47'>Marital Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_5_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Married' >Married<\/option><option value='Divorced' >Divorced<\/option><option value='Single' >Single<\/option><option value='Widowed' >Widowed<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_5_48\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_48\" ><label class='gfield_label gform-field-label' for='input_5_48'>Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_5_48' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_21' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"2\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_21' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-21' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_39\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_39\" >Please provide information about any current primary care provider below.<\/div><fieldset id=\"field_5_40\" class=\"gfield gfield--type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doctor\/Other Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_40'>\n                            \n                            <span id='input_5_40_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.3' id='input_5_40_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_40_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_40_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_40.6' id='input_5_40_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_40_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Physician Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_41' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_41_1_container' >\n                                        <input type='text' name='input_41.1' id='input_5_41_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_41_1' id='input_5_41_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_41_2_container' >\n                                        <input type='text' name='input_41.2' id='input_5_41_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_41_2' id='input_5_41_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_41_3_container' >\n                                    <input type='text' name='input_41.3' id='input_5_41_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_41_3' id='input_5_41_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_41_4_container' >\n                                        <input type='text' name='input_41.4' id='input_5_41_4' value=''      aria-required='false'    \/>\n                                        <label for='input_5_41_4' id='input_5_41_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_41_5_container' >\n                                    <input type='text' name='input_41.5' id='input_5_41_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_41_5' id='input_5_41_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_41.6' id='input_5_41_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_42\" ><label class='gfield_label gform-field-label' for='input_5_42'>Physician Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_5_42' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_43\" ><legend class='gfield_label gform-field-label' >May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_43'>\n\t\t\t<div class='gchoice gchoice_5_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Yes'  id='choice_5_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_0' id='label_5_43_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_5_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_1' id='label_5_43_1' class='gform-field-label gform-field-label--type-inline'>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_5_46' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"3\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_46' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_5' class='gform_page' data-js='page-field-id-46' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_51\" ><legend class='gfield_label gform-field-label' >What is (are) your purpose (s) for participation in this HRT Program?<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_5_51'>\n\t\t\t<div class='gchoice gchoice_5_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='To determine my current level of health and to receive recommendations for an HRT program.'  id='choice_5_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_0' id='label_5_51_0' class='gform-field-label gform-field-label--type-inline'>To determine my current level of health and to receive recommendations for an HRT program.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Other (please explain below)'  id='choice_5_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_1' id='label_5_51_1' class='gform-field-label gform-field-label--type-inline'>Other (please explain below)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_53\" ><label class='gfield_label gform-field-label' for='input_5_53'>Explain what is (are) your purpose (s) for participation in this HRT Program?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_5_53' class='textarea small'    placeholder='Use this area to explain other reasons for participation in this HRT program.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_55\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Present Medical History<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_55'><div class='gchoice gchoice_5_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Has a doctor ever said your blood pressure was too high'  id='choice_5_55_1'   aria-describedby=\"gfield_description_5_55\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_1' id='label_5_55_1' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever said your blood pressure was too high<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.2' type='checkbox'  value='Do you ever have pain in your chest or heart'  id='choice_5_55_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_2' id='label_5_55_2' class='gform-field-label gform-field-label--type-inline'>Do you ever have pain in your chest or heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.3' type='checkbox'  value='Are you often bothered by a thumping of the heart'  id='choice_5_55_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_3' id='label_5_55_3' class='gform-field-label gform-field-label--type-inline'>Are you often bothered by a thumping of the heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.4' type='checkbox'  value='Does your heart often race'  id='choice_5_55_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_4' id='label_5_55_4' class='gform-field-label gform-field-label--type-inline'>Does your heart often race<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.5' type='checkbox'  value='Extra heartbeats or skipped beats'  id='choice_5_55_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_5' id='label_5_55_5' class='gform-field-label gform-field-label--type-inline'>Extra heartbeats or skipped beats<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.6' type='checkbox'  value='Are your ankles often badly swollen'  id='choice_5_55_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_6' id='label_5_55_6' class='gform-field-label gform-field-label--type-inline'>Are your ankles often badly swollen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.7' type='checkbox'  value='Do cold hands or feet trouble you even in hot weather'  id='choice_5_55_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_7' id='label_5_55_7' class='gform-field-label gform-field-label--type-inline'>Do cold hands or feet trouble you even in hot weather<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.8' type='checkbox'  value='Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary'  id='choice_5_55_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_8' id='label_5_55_8' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.9' type='checkbox'  value='Do you suffer from frequent cramps in your legs'  id='choice_5_55_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_9' id='label_5_55_9' class='gform-field-label gform-field-label--type-inline'>Do you suffer from frequent cramps in your legs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.11' type='checkbox'  value='Do you often have difficulty breathing'  id='choice_5_55_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_11' id='label_5_55_11' class='gform-field-label gform-field-label--type-inline'>Do you often have difficulty breathing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.12' type='checkbox'  value='Do you get out of breath long before anyone else'  id='choice_5_55_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_12' id='label_5_55_12' class='gform-field-label gform-field-label--type-inline'>Do you get out of breath long before anyone else<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.13' type='checkbox'  value='Do you sometimes get out of breath when sitting still or sleeping'  id='choice_5_55_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_13' id='label_5_55_13' class='gform-field-label gform-field-label--type-inline'>Do you sometimes get out of breath when sitting still or sleeping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.14' type='checkbox'  value='Has a doctor ever told you your cholesterol level was high'  id='choice_5_55_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_14' id='label_5_55_14' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you your cholesterol level was high<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.15' type='checkbox'  value='Has a doctor ever told you that you have an abdominal aortic aneurysm'  id='choice_5_55_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_15' id='label_5_55_15' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you that you have an abdominal aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_55_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.16' type='checkbox'  value='Has a doctor ever told you that you have critical aortic stenosis'  id='choice_5_55_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_55_16' id='label_5_55_16' class='gform-field-label gform-field-label--type-inline'>Has a doctor ever told you that you have critical aortic stenosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_55'>Check those questions to which you answer yes (leave the others blank).\n<\/div><\/fieldset><fieldset id=\"field_5_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_57\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you now have or have you recently experienced:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_57'><div class='gchoice gchoice_5_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Chronic, recurrent or morning cough'  id='choice_5_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_1' id='label_5_57_1' class='gform-field-label gform-field-label--type-inline'>Chronic, recurrent or morning cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='Episode of coughing up blood'  id='choice_5_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_2' id='label_5_57_2' class='gform-field-label gform-field-label--type-inline'>Episode of coughing up blood<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Increased anxiety or depression'  id='choice_5_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_3' id='label_5_57_3' class='gform-field-label gform-field-label--type-inline'>Increased anxiety or depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Problems with recurrent fatigue, trouble sleeping or increased irritability'  id='choice_5_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_4' id='label_5_57_4' class='gform-field-label gform-field-label--type-inline'>Problems with recurrent fatigue, trouble sleeping or increased irritability<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Migraine or recurrent headaches'  id='choice_5_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_5' id='label_5_57_5' class='gform-field-label gform-field-label--type-inline'>Migraine or recurrent headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Swollen or painful knees or ankles'  id='choice_5_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_6' id='label_5_57_6' class='gform-field-label gform-field-label--type-inline'>Swollen or painful knees or ankles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.7' type='checkbox'  value='Swollen, stiff or painful joints'  id='choice_5_57_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_7' id='label_5_57_7' class='gform-field-label gform-field-label--type-inline'>Swollen, stiff or painful joints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.8' type='checkbox'  value='Pain in your legs after walking short distances'  id='choice_5_57_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_8' id='label_5_57_8' class='gform-field-label gform-field-label--type-inline'>Pain in your legs after walking short distances<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.9' type='checkbox'  value='Foot problems'  id='choice_5_57_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_9' id='label_5_57_9' class='gform-field-label gform-field-label--type-inline'>Foot problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.11' type='checkbox'  value='Back problems'  id='choice_5_57_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_11' id='label_5_57_11' class='gform-field-label gform-field-label--type-inline'>Back problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.12' type='checkbox'  value='Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea'  id='choice_5_57_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_12' id='label_5_57_12' class='gform-field-label gform-field-label--type-inline'>Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.13' type='checkbox'  value='Significant vision or hearing problems'  id='choice_5_57_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_13' id='label_5_57_13' class='gform-field-label gform-field-label--type-inline'>Significant vision or hearing problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.14' type='checkbox'  value='Recent change in a wart or a mole'  id='choice_5_57_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_14' id='label_5_57_14' class='gform-field-label gform-field-label--type-inline'>Recent change in a wart or a mole<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.15' type='checkbox'  value='Glaucoma or increased pressure in the eyes'  id='choice_5_57_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_15' id='label_5_57_15' class='gform-field-label gform-field-label--type-inline'>Glaucoma or increased pressure in the eyes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.16' type='checkbox'  value='Exposure to loud noises for long periods'  id='choice_5_57_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_16' id='label_5_57_16' class='gform-field-label gform-field-label--type-inline'>Exposure to loud noises for long periods<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.17' type='checkbox'  value='An infection such as pneumonia accompanied by a fever'  id='choice_5_57_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_17' id='label_5_57_17' class='gform-field-label gform-field-label--type-inline'>An infection such as pneumonia accompanied by a fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.18' type='checkbox'  value='Significant unexplained weight loss'  id='choice_5_57_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_18' id='label_5_57_18' class='gform-field-label gform-field-label--type-inline'>Significant unexplained weight loss<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.19' type='checkbox'  value='A fever, which can cause dehydration and rapid heartbeat'  id='choice_5_57_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_19' id='label_5_57_19' class='gform-field-label gform-field-label--type-inline'>A fever, which can cause dehydration and rapid heartbeat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.21' type='checkbox'  value='A deep vein thrombosis (blood clot)'  id='choice_5_57_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_21' id='label_5_57_21' class='gform-field-label gform-field-label--type-inline'>A deep vein thrombosis (blood clot)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.22' type='checkbox'  value='A hernia that is causing symptoms'  id='choice_5_57_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_22' id='label_5_57_22' class='gform-field-label gform-field-label--type-inline'>A hernia that is causing symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.23' type='checkbox'  value='Foot or ankle sores that won&#039;t heal'  id='choice_5_57_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_23' id='label_5_57_23' class='gform-field-label gform-field-label--type-inline'>Foot or ankle sores that won't heal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.24' type='checkbox'  value='Persistent pain or problems walking after you have fallen'  id='choice_5_57_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_24' id='label_5_57_24' class='gform-field-label gform-field-label--type-inline'>Persistent pain or problems walking after you have fallen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.25' type='checkbox'  value='Eye conditions such as bleeding in the retina or detached retina'  id='choice_5_57_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_25' id='label_5_57_25' class='gform-field-label gform-field-label--type-inline'>Eye conditions such as bleeding in the retina or detached retina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.26' type='checkbox'  value='Cataract or lens transplant'  id='choice_5_57_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_26' id='label_5_57_26' class='gform-field-label gform-field-label--type-inline'>Cataract or lens transplant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_57_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.27' type='checkbox'  value='Laser treatment or other eye surgery'  id='choice_5_57_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_57_27' id='label_5_57_27' class='gform-field-label gform-field-label--type-inline'>Laser treatment or other eye surgery<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_88\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_88\" ><label class='gfield_label gform-field-label' for='input_5_88'>Additional Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_5_88' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"4\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_59' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_6' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you have:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_60'><div class='gchoice gchoice_5_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Menstrual period problems'  id='choice_5_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_1' id='label_5_60_1' class='gform-field-label gform-field-label--type-inline'>Menstrual period problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Significant childbirth - related problems'  id='choice_5_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_2' id='label_5_60_2' class='gform-field-label gform-field-label--type-inline'>Significant childbirth - related problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Urine loss when you cough, sneeze or laugh'  id='choice_5_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_60_3' id='label_5_60_3' class='gform-field-label gform-field-label--type-inline'>Urine loss when you cough, sneeze or laugh<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_61\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_61\" ><label class='gfield_label gform-field-label' for='input_5_61'>Date of last pelvic exam\/pap smear<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_5_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_61_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_61_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_61' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_62\" ><label class='gfield_label gform-field-label' for='input_5_62'>Additional Comments regarding female specific sexual based health history<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_5_62' class='textarea small'  aria-describedby=\"gfield_description_5_62\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_5_62'>Please use this area to add additional comments regarding female specific sexual based health history.<\/div><\/div><fieldset id=\"field_5_63\" class=\"gfield gfield--type-list gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_63\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List any prescription medications you are now taking<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Prescription Medicines<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_63_cell1 gform-grid-col' data-label='Prescription Medicines'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_63\" aria-label='Prescription Medicines, Row 1' data-aria-label-template='Prescription Medicines, Row {0}' type='text' name='input_63[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 8)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 8)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_63'>Please use the plus button to the right to add all medicine you're currently taking.<\/div><\/fieldset><fieldset id=\"field_5_64\" class=\"gfield gfield--type-list gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List any self-prescribed medications, dietary supplements, or vitamins you are now taking<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Other supplements<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_64_cell1 gform-grid-col' data-label='Other supplements'><input aria-invalid='false'  aria-describedby=\"gfield_description_5_64\" aria-label='Other supplements, Row 1' data-aria-label-template='Other supplements, Row {0}' type='text' name='input_64[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 8)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 8)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_64'>Please use the plus button to the right to add all medicine you're currently taking.<\/div><\/fieldset><div id=\"field_5_65\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_65\" ><label class='gfield_label gform-field-label' for='input_5_65'>Date of last complete physical examination<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_65' id='input_5_65' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_65_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_65_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_65' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_66\" ><legend class='gfield_label gform-field-label' >Outcome of last physical exam<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_66'>\n\t\t\t<div class='gchoice gchoice_5_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Normal'  id='choice_5_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_0' id='label_5_66_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Abnormal'  id='choice_5_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_1' id='label_5_66_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Never'  id='choice_5_66_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_2' id='label_5_66_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_66_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_66_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_66_3' id='label_5_66_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_67\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_67\" ><label class='gfield_label gform-field-label' for='input_5_67'>Date of last chest X-ray<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_67' id='input_5_67' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_67_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_67_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_67' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_68\" ><legend class='gfield_label gform-field-label' >Outcome of last chest X-Ray<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_68'>\n\t\t\t<div class='gchoice gchoice_5_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Normal'  id='choice_5_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_0' id='label_5_68_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Abnormal'  id='choice_5_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_1' id='label_5_68_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Never'  id='choice_5_68_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_2' id='label_5_68_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_68_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_3' id='label_5_68_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_69\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_69\" ><label class='gfield_label gform-field-label' for='input_5_69'>Date of last electrocardiogram (EKG or ECG)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_69' id='input_5_69' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_69_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_69_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_69' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_70\" ><legend class='gfield_label gform-field-label' >Outcome of last (EKG or ECG)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_70'>\n\t\t\t<div class='gchoice gchoice_5_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Normal'  id='choice_5_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_0' id='label_5_70_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Abnormal'  id='choice_5_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_1' id='label_5_70_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Never'  id='choice_5_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_2' id='label_5_70_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_70_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_70_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_70_3' id='label_5_70_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_71\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_71\" ><label class='gfield_label gform-field-label' for='input_5_71'>Date of last dental checkup<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_5_71' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_71_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_71_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_71' class='gform_hidden' value='https:\/\/premieralternativemeds.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_72\" ><legend class='gfield_label gform-field-label' >Outcome of last dental checkup<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_72'>\n\t\t\t<div class='gchoice gchoice_5_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Normal'  id='choice_5_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_0' id='label_5_72_0' class='gform-field-label gform-field-label--type-inline'>Normal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Abnormal'  id='choice_5_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_1' id='label_5_72_1' class='gform-field-label gform-field-label--type-inline'>Abnormal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Never'  id='choice_5_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_2' id='label_5_72_2' class='gform-field-label gform-field-label--type-inline'>Never<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_72_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Can&#039;t Remember\/Other'  id='choice_5_72_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_72_3' id='label_5_72_3' class='gform-field-label gform-field-label--type-inline'>Can't Remember\/Other<\/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_5_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"5\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_50' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"7\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"7\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_7' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_5_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_74\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Past Medical History<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_74'><div class='gchoice gchoice_5_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Rheumatic Fever'  id='choice_5_74_1'   aria-describedby=\"gfield_description_5_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Heart murmur'  id='choice_5_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_2' id='label_5_74_2' class='gform-field-label gform-field-label--type-inline'>Heart murmur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Diseases of the arteries'  id='choice_5_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_3' id='label_5_74_3' class='gform-field-label gform-field-label--type-inline'>Diseases of the arteries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Varicose veins'  id='choice_5_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_4' id='label_5_74_4' class='gform-field-label gform-field-label--type-inline'>Varicose veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='Arthritis of legs or arms'  id='choice_5_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_5' id='label_5_74_5' class='gform-field-label gform-field-label--type-inline'>Arthritis of legs or arms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Diabetes or abnormal blood-sugar tests'  id='choice_5_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_6' id='label_5_74_6' class='gform-field-label gform-field-label--type-inline'>Diabetes or abnormal blood-sugar tests<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.7' type='checkbox'  value='Phlebitis (inflammation of a vein)'  id='choice_5_74_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_7' id='label_5_74_7' class='gform-field-label gform-field-label--type-inline'>Phlebitis (inflammation of a vein)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.8' type='checkbox'  value='Dizziness or fainting spells'  id='choice_5_74_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_8' id='label_5_74_8' class='gform-field-label gform-field-label--type-inline'>Dizziness or fainting spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.9' type='checkbox'  value='Epilepsy or seizures'  id='choice_5_74_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_9' id='label_5_74_9' class='gform-field-label gform-field-label--type-inline'>Epilepsy or seizures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.11' type='checkbox'  value='Stroke'  id='choice_5_74_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_11' id='label_5_74_11' class='gform-field-label gform-field-label--type-inline'>Stroke<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.12' type='checkbox'  value='Diphtheria'  id='choice_5_74_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_12' id='label_5_74_12' class='gform-field-label gform-field-label--type-inline'>Diphtheria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.13' type='checkbox'  value='Scarlet Fever'  id='choice_5_74_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_13' id='label_5_74_13' class='gform-field-label gform-field-label--type-inline'>Scarlet Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.14' type='checkbox'  value='Infectious mononucleosis'  id='choice_5_74_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_14' id='label_5_74_14' class='gform-field-label gform-field-label--type-inline'>Infectious mononucleosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.15' type='checkbox'  value='Nervous or emotional problems'  id='choice_5_74_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_15' id='label_5_74_15' class='gform-field-label gform-field-label--type-inline'>Nervous or emotional problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.16' type='checkbox'  value='Anemia'  id='choice_5_74_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_16' id='label_5_74_16' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.17' type='checkbox'  value='Thyroid problems'  id='choice_5_74_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_17' id='label_5_74_17' class='gform-field-label gform-field-label--type-inline'>Thyroid problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.18' type='checkbox'  value='Pneumonia'  id='choice_5_74_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_18' id='label_5_74_18' class='gform-field-label gform-field-label--type-inline'>Pneumonia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.19' type='checkbox'  value='Bronchitis'  id='choice_5_74_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_19' id='label_5_74_19' class='gform-field-label gform-field-label--type-inline'>Bronchitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.21' type='checkbox'  value='Asthma'  id='choice_5_74_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_21' id='label_5_74_21' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.22' type='checkbox'  value='Abnormal chest X-ray'  id='choice_5_74_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_22' id='label_5_74_22' class='gform-field-label gform-field-label--type-inline'>Abnormal chest X-ray<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.23' type='checkbox'  value='Other lung disease'  id='choice_5_74_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_23' id='label_5_74_23' class='gform-field-label gform-field-label--type-inline'>Other lung disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.24' type='checkbox'  value='Injuries to back, arms, legs or joint'  id='choice_5_74_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_24' id='label_5_74_24' class='gform-field-label gform-field-label--type-inline'>Injuries to back, arms, legs or joint<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.25' type='checkbox'  value='Broken bones'  id='choice_5_74_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_25' id='label_5_74_25' class='gform-field-label gform-field-label--type-inline'>Broken bones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.26' type='checkbox'  value='Jaundice or gallbladder problems'  id='choice_5_74_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_26' id='label_5_74_26' class='gform-field-label gform-field-label--type-inline'>Jaundice or gallbladder problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_74_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.27' type='checkbox'  value='Heart attack (if yes, enter years below)'  id='choice_5_74_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_74_27' id='label_5_74_27' class='gform-field-label gform-field-label--type-inline'>Heart attack (if yes, enter years below)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_74'>Check those questions to which your answer is yes (leave others blank).\n<\/div><\/fieldset><div id=\"field_5_75\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_75\" ><label class='gfield_label gform-field-label' for='input_5_75'>How many years ago did you have heart attack?<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_5_75' type='text' value='' class='small'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_76\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_76\" ><label class='gfield_label gform-field-label' for='input_5_76'>Additional comments about past medical history<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_76' id='input_5_76' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_77' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"6\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_5_77' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_5\").val(\"8\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_5\").val(\"8\");  jQuery(\"#gform_5\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_8' class='gform_page' data-js='page-field-id-77' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_79\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_79\" ><\/div><fieldset id=\"field_5_78\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_78\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Low Testosterone symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_78'><div class='gchoice gchoice_5_78_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.1' type='checkbox'  value='Sexual dysfunction'  id='choice_5_78_1'   aria-describedby=\"gfield_description_5_78\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>Sexual dysfunction<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.2' type='checkbox'  value='Body fatigue or weakness'  id='choice_5_78_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_2' id='label_5_78_2' class='gform-field-label gform-field-label--type-inline'>Body fatigue or weakness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.3' type='checkbox'  value='Depression or anxiety'  id='choice_5_78_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_3' id='label_5_78_3' class='gform-field-label gform-field-label--type-inline'>Depression or anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.4' type='checkbox'  value='Increased body fat'  id='choice_5_78_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_4' id='label_5_78_4' class='gform-field-label gform-field-label--type-inline'>Increased body fat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_78_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_78.5' type='checkbox'  value='Increased irritability'  id='choice_5_78_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_78_5' id='label_5_78_5' class='gform-field-label gform-field-label--type-inline'>Increased irritability<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_78'>Check box that pertains to you.<\/div><\/fieldset><fieldset id=\"field_5_80\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_80\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Sexual dysfunction symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_80'><div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.1' type='checkbox'  value='Inability to get an erection'  id='choice_5_80_1'   aria-describedby=\"gfield_description_5_80\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>Inability to get an erection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_80_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.2' type='checkbox'  value='Difficulty maintaining an erection'  id='choice_5_80_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_2' id='label_5_80_2' class='gform-field-label gform-field-label--type-inline'>Difficulty maintaining an erection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_80_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_80.3' type='checkbox'  value='Reduced sex drive'  id='choice_5_80_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_80_3' id='label_5_80_3' class='gform-field-label gform-field-label--type-inline'>Reduced sex drive<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_80'>Check box that pertains to you.<\/div><\/fieldset><fieldset id=\"field_5_81\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_81\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anabolic necessity symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_81'><div class='gchoice gchoice_5_81_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.1' type='checkbox'  value='Have you lost weight or muscle tissue from surgery, trauma, or depression'  id='choice_5_81_1'   aria-describedby=\"gfield_description_5_81\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>Have you lost weight or muscle tissue from surgery, trauma, or depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_81_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.2' type='checkbox'  value='Do you suffer from anemia'  id='choice_5_81_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_2' id='label_5_81_2' class='gform-field-label gform-field-label--type-inline'>Do you suffer from anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_81_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.3' type='checkbox'  value='Difficulty gaining or maintaining weight'  id='choice_5_81_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_3' id='label_5_81_3' class='gform-field-label gform-field-label--type-inline'>Difficulty gaining or maintaining weight<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_81_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.4' type='checkbox'  value='Do you have significant joint pain'  id='choice_5_81_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_4' id='label_5_81_4' class='gform-field-label gform-field-label--type-inline'>Do you have significant joint pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_81_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_81.5' type='checkbox'  value='Do you suffer muscle soreness and fatigue'  id='choice_5_81_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_81_5' id='label_5_81_5' class='gform-field-label gform-field-label--type-inline'>Do you suffer muscle soreness and fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_81'>Check the box that pertains to you.\n<\/div><\/fieldset><fieldset id=\"field_5_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_82\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Low HGH symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_82'><div class='gchoice gchoice_5_82_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.1' type='checkbox'  value='High levels of body fat'  id='choice_5_82_1'   aria-describedby=\"gfield_description_5_82\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>High levels of body fat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.2' type='checkbox'  value='Anxiety and depression'  id='choice_5_82_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_2' id='label_5_82_2' class='gform-field-label gform-field-label--type-inline'>Anxiety and depression<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.3' type='checkbox'  value='Decreased sexual desire'  id='choice_5_82_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_3' id='label_5_82_3' class='gform-field-label gform-field-label--type-inline'>Decreased sexual desire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.4' type='checkbox'  value='Overall fatigue'  id='choice_5_82_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_4' id='label_5_82_4' class='gform-field-label gform-field-label--type-inline'>Overall fatigue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.5' type='checkbox'  value='Muscle atrophy'  id='choice_5_82_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_5' id='label_5_82_5' class='gform-field-label gform-field-label--type-inline'>Muscle atrophy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.6' type='checkbox'  value='Hard to fall asleep'  id='choice_5_82_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_6' id='label_5_82_6' class='gform-field-label gform-field-label--type-inline'>Hard to fall asleep<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_82_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.7' type='checkbox'  value='Reduced ability to stay asleep'  id='choice_5_82_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_82_7' id='label_5_82_7' class='gform-field-label gform-field-label--type-inline'>Reduced ability to stay asleep<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_5_82'>Check the box that pertains to you.\n<\/div><\/fieldset><fieldset id=\"field_5_84\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_5_84\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Difficulty losing weight symptoms<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_84'><div class='gchoice gchoice_5_84_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.1' type='checkbox'  value='Metabolic syndrome\/caffeine doesn&#039;t work anymore'  id='choice_5_84_1'   aria-describedby=\"gfield_description_5_84\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>Metabolic syndrome\/caffeine doesn't work anymore<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_84_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.2' type='checkbox'  value='Insulin resistance'  id='choice_5_84_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_84_2' id='label_5_84_2' class='gform-field-label gform-field-label--type-inline'>Insulin resistance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_84_3'>\n\t\t\t\t\t\t\t\t<input 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