- Scan ID:
- a2466db7-261b-4770-add1-32e23f00e690Finished
- Submitted URL:
- https://rwl.io/3XHY9nPRedirected
- Report Finished:
Links · 5 found
The outgoing links identified from the page
| Link | Text |
|---|---|
| https://www.patientconnect365.com/Dentists/Utah/SouthJordan/84095/Copper_Creek_Dental_clrc2j | |
| https://www.patientconnect365.com/Home/PrivacyPolicy | Privacy Policy |
| https://www.patientconnect365.com/Home/TermsOfUse | Terms of Use |
| https://www.patientconnect365.com/MicrositeContact/Utah/SouthJordan/84095/Copper_Creek_Dental_clrc2j | Contact Us |
| https://www.patientconnect365.com | PatientConnect365 |
JavaScript Variables · 9 found
Global JavaScript variables loaded on the window object of a page, are variables declared outside of functions and accessible from anywhere in the code within the current scope
| Name | Type |
|---|---|
| onbeforetoggle | object |
| documentPictureInPicture | object |
| onscrollend | object |
| $ | function |
| jQuery | function |
| define | undefined |
| app | object |
| toastr | object |
| page | object |
Console log messages · 0 found
Messages logged to the web console
HTML
The raw HTML body of the page
<!DOCTYPE html><html><head>
<meta charset="utf-8">
<meta content="width=device-width, initial-scale=1.0" name="viewport">
<title>Copper Creek Dental - Patient Forms</title>
<link rel="icon" href="/favicon.ico" type="image/x-icon">
<link rel="shortcut icon" href="/favicon.ico" type="image/x-icon">
<link rel="stylesheet" type="text/css" href="/Content/built/css/site.css">
<link rel="stylesheet" type="text/css" href="https://fonts.googleapis.com/css?family=Roboto:400,300,400italic,500,500italic,700,700italic">
<script src="/content/built/app.js"></script>
<script src="/content/scripts/toastr/toastr.js"></script>
<link href="/content/less/toastr/toastr.css" rel="stylesheet">
<style></style></head>
<body class="inner-page">
<div id="wrapper" itemscope="" itemtype="http://schema.org/Dentist">
<header id="header">
<div class="header__top-line">
<div class="header__box-holder">
</div>
</div>
<div class="header-logo header__box-holder mob-hidden" style="background: url(https://d26ogar5mbvu9a.cloudfront.net/Images/Site_5d4f0ce1a97f4aab927833001695708a.png)">
<strong class="b-logo"><a href="https://www.patientconnect365.com/Dentists/Utah/SouthJordan/84095/Copper_Creek_Dental_clrc2j" class="b-logo__link"><img src="https://d26ogar5mbvu9a.cloudfront.net/Images/Site_0e262002e05144a38b5877a2fd64555a.png" alt="Copper Creek Dental" class="logo__logo-img"></a></strong>
</div>
</header>
<main role="main" class="inner-boxes-wrap">
<form action="/21464/form/159219911/SaveCustomForm" method="post" class="steps-form" data-role="custom-form">
<div class="inner-box">
<h3 class="title-h3">
<span class="text-gray">Form: </span>FUSE Medical History
</h3>
<ol class="b-steps b-grid-wrap">
<li class="b-grid-wrap__box--size-25">
<a class="b-steps__step b-steps__step--active">Page 1</a>
</li>
<li class="b-grid-wrap__box--size-25">
<a class="b-steps__step ">Confirm</a>
</li>
</ol>
</div>
<div id="patient-info" class="inner-box" data-role="section">
<h3 class="title-h3">Patient Information</h3>
<div class="b-inner-form b-grid-wrap b-grid-wrap--offset">
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="FirstName">FIRST Name</label>
<input type="text" id="FirstName" name="FirstName" value="" data-role="value" data-type="text" class="b-inner-form__input" data-required="" maxlength="40">
<span class="validation-message" data-role="validation-message" data-target="FirstName"></span>
</div>
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="LastName">LAST Name</label>
<input type="text" id="LastName" name="LastName" value="" data-role="value" data-type="text" class="b-inner-form__input" data-required="" maxlength="40">
<span class="validation-message" data-role="validation-message" data-target="LastName"></span>
</div>
<div class="b-inner-form__input-wrap b-grid-wrap__box--size-25">
<label class="b-inner-form__label" for="MiddleInitial">MI</label>
<input type="text" id="MiddleInitial" name="MiddleInitial" value="" data-role="value" data-type="text" class="b-inner-form__input b-inner-form__input--xs" maxlength="2">
<span class="validation-message" data-role="validation-message" data-target="MiddleInitial"></span>
</div>
</div>
</div>
<div class="inner-box" id="section-100365886">
<h3 class="title-h3">Emergency Contact</h3>
<div data-role="editable-comment" data-required="">
<label for="comment-101899461" class="b-inner-form__label">Name of Emergency Contact</label>
<input id="comment-101899461" name="comment-101899461" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
<div data-role="editable-comment" data-required="">
<label for="comment-101899462" class="b-inner-form__label">Phone Number of Emergency Contact</label>
<input id="comment-101899462" name="comment-101899462" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
<div data-role="editable-comment" data-required="">
<label for="comment-101899463" class="b-inner-form__label">Relationship of Emergency Contact</label>
<input id="comment-101899463" name="comment-101899463" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
</div>
<div class="inner-box" id="section-100365887">
<h3 class="title-h3">Pharmacy Information</h3>
<div data-role="editable-comment" data-required="">
<label for="comment-101899464" class="b-inner-form__label">Name of Pharmacy</label>
<input id="comment-101899464" name="comment-101899464" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
<div data-role="editable-comment" data-required="">
<label for="comment-101899465" class="b-inner-form__label">Pharmacy Address</label>
<input id="comment-101899465" name="comment-101899465" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
</div>
<div class="inner-box" id="section-100365888">
<h3 class="title-h3">Do you have any of the following diseases or problems?</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Active Tuberculosis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899466-yes" name="answer-101899466" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899466-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899466-no" name="answer-101899466" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899466-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Persistent cough greater than a 3 week duration</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899467-yes" name="answer-101899467" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899467-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899467-no" name="answer-101899467" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899467-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Cough that produces blood</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899468-yes" name="answer-101899468" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899468-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899468-no" name="answer-101899468" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899468-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Been exposed to anyone with tuberculosis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899469-yes" name="answer-101899469" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899469-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899469-no" name="answer-101899469" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899469-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
</div>
<div class="inner-box" id="section-100365889">
<h3 class="title-h3">Medical History</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Are you now under the care of a physician?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899470-yes" name="answer-101899470" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899470-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899470-no" name="answer-101899470" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899470-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899470" name="answer-comment-101899470" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Are you in good health?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899471-yes" name="answer-101899471" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899471-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899471-no" name="answer-101899471" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899471-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text"> Has there been any change in your general health within the past year?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899472-yes" name="answer-101899472" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899472-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899472-no" name="answer-101899472" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899472-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899472" name="answer-comment-101899472" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Have you had a serious illness, operation or been hospitalized in the past 5 years?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899473-yes" name="answer-101899473" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899473-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899473-no" name="answer-101899473" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899473-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899473" name="answer-comment-101899473" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Are you taking or have you recently taken any prescription or over the counter medicine(s)?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899474-yes" name="answer-101899474" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899474-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899474-no" name="answer-101899474" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899474-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899474" name="answer-comment-101899474" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Do you wear contact lenses?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899475-yes" name="answer-101899475" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899475-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899475-no" name="answer-101899475" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899475-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Joint Replacement. Have you had any orthopedic total joint (hip, knee, elbow, finger) replacement?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899476-yes" name="answer-101899476" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899476-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899476-no" name="answer-101899476" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899476-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899476" name="answer-comment-101899476" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget's disease?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899477-yes" name="answer-101899477" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899477-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899477-no" name="answer-101899477" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899477-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899477" name="answer-comment-101899477" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous biphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899478-yes" name="answer-101899478" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899478-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899478-no" name="answer-101899478" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899478-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899478" name="answer-comment-101899478" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Do you use controlled substances (drugs)?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899479-yes" name="answer-101899479" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899479-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899479-no" name="answer-101899479" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899479-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899479" name="answer-comment-101899479" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Do you use tobacco (smoking, snuff, chew, bidis)? </span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899480-yes" name="answer-101899480" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899480-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899480-no" name="answer-101899480" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899480-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899480" name="answer-comment-101899480" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Do you drink alcoholic beverages?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899481-yes" name="answer-101899481" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899481-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899481-no" name="answer-101899481" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899481-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
</div>
<div class="inner-box" id="section-100365890">
<h3 class="title-h3">WOMEN ONLY. Are you:</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Pregnant</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899482-yes" name="answer-101899482" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899482-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899482-no" name="answer-101899482" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899482-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899482" name="answer-comment-101899482" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Taking birth control pills or hormonal replacement?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899483-yes" name="answer-101899483" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899483-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899483-no" name="answer-101899483" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899483-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Nursing?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899484-yes" name="answer-101899484" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899484-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899484-no" name="answer-101899484" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899484-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
</div>
<div class="inner-box" id="section-100365891">
<h3 class="title-h3">Allergies, Are you allergic to or have you had any reaction to:</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Local anesthetics</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899485-yes" name="answer-101899485" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899485-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899485-no" name="answer-101899485" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899485-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Aspirin</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899486-yes" name="answer-101899486" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899486-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899486-no" name="answer-101899486" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899486-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Penicillin or other antibiotics</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899487-yes" name="answer-101899487" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899487-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899487-no" name="answer-101899487" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899487-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Barbiturates, sedatives, or sleeping pills</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899488-yes" name="answer-101899488" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899488-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899488-no" name="answer-101899488" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899488-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Sulfa drugs</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899489-yes" name="answer-101899489" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899489-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899489-no" name="answer-101899489" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899489-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Codeine or other narcotics</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899490-yes" name="answer-101899490" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899490-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899490-no" name="answer-101899490" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899490-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Metals</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899491-yes" name="answer-101899491" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899491-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899491-no" name="answer-101899491" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899491-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Latex (rubber)</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899492-yes" name="answer-101899492" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899492-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899492-no" name="answer-101899492" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899492-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Iodine</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899493-yes" name="answer-101899493" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899493-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899493-no" name="answer-101899493" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899493-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Hay fever/seasonal</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899494-yes" name="answer-101899494" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899494-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899494-no" name="answer-101899494" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899494-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Animals</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899495-yes" name="answer-101899495" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899495-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899495-no" name="answer-101899495" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899495-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Food</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899496-yes" name="answer-101899496" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899496-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899496-no" name="answer-101899496" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899496-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Other</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899497-yes" name="answer-101899497" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899497-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899497-no" name="answer-101899497" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899497-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899497" name="answer-comment-101899497" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
</div>
<div class="inner-box" id="section-100365892">
<h3 class="title-h3">Congenital Heart Disease (CHD) - Please indicate if you have had or not had any of the following:</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text"> Artificial (prosthetic) heart valve</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899498-yes" name="answer-101899498" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899498-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899498-no" name="answer-101899498" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899498-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Previous infective endocarditis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899499-yes" name="answer-101899499" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899499-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899499-no" name="answer-101899499" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899499-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Damaged valves in transplanted heart</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899500-yes" name="answer-101899500" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899500-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899500-no" name="answer-101899500" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899500-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Congenital heart disease (CHD)</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899501-yes" name="answer-101899501" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899501-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899501-no" name="answer-101899501" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899501-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Unrepaired, cyanotic CHD</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899502-yes" name="answer-101899502" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899502-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899502-no" name="answer-101899502" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899502-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Repaired (completely) in the last 6 months</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899503-yes" name="answer-101899503" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899503-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899503-no" name="answer-101899503" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899503-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Repaired CHD with residual defects</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899504-yes" name="answer-101899504" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899504-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899504-no" name="answer-101899504" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899504-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
</div>
<div class="inner-box" id="section-100365893">
<h3 class="title-h3">Other Diseases and Conditions - Please indicate if you have had or not had any of the following:</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text"> Cardiovascular disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899505-yes" name="answer-101899505" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899505-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899505-no" name="answer-101899505" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899505-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Angina</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899506-yes" name="answer-101899506" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899506-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899506-no" name="answer-101899506" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899506-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Arteriosclerosis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899507-yes" name="answer-101899507" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899507-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899507-no" name="answer-101899507" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899507-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Congestive heart failure</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899508-yes" name="answer-101899508" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899508-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899508-no" name="answer-101899508" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899508-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Damaged heart valves</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899509-yes" name="answer-101899509" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899509-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899509-no" name="answer-101899509" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899509-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Heart attack</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899510-yes" name="answer-101899510" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899510-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899510-no" name="answer-101899510" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899510-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Heart murmur</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899511-yes" name="answer-101899511" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899511-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899511-no" name="answer-101899511" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899511-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Low blood pressure</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899512-yes" name="answer-101899512" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899512-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899512-no" name="answer-101899512" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899512-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">High blood pressure</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899513-yes" name="answer-101899513" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899513-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899513-no" name="answer-101899513" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899513-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Other congenital heart defects</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899514-yes" name="answer-101899514" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899514-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899514-no" name="answer-101899514" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899514-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Mitral valve prolapse</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899515-yes" name="answer-101899515" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899515-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899515-no" name="answer-101899515" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899515-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Pacemaker</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899516-yes" name="answer-101899516" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899516-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899516-no" name="answer-101899516" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899516-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Rheumatic fever</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899517-yes" name="answer-101899517" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899517-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899517-no" name="answer-101899517" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899517-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Rheumatic heart disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899518-yes" name="answer-101899518" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899518-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899518-no" name="answer-101899518" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899518-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Abnormal bleeding</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899519-yes" name="answer-101899519" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899519-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899519-no" name="answer-101899519" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899519-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Anemia</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899520-yes" name="answer-101899520" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899520-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899520-no" name="answer-101899520" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899520-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Blood transfusion</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899521-yes" name="answer-101899521" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899521-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899521-no" name="answer-101899521" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899521-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899521" name="answer-comment-101899521" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Hemophilia</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899522-yes" name="answer-101899522" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899522-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899522-no" name="answer-101899522" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899522-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">AIDS or HIV</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899523-yes" name="answer-101899523" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899523-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899523-no" name="answer-101899523" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899523-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Arthritis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899524-yes" name="answer-101899524" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899524-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899524-no" name="answer-101899524" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899524-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Autoimmune disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899525-yes" name="answer-101899525" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899525-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899525-no" name="answer-101899525" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899525-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899525" name="answer-comment-101899525" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Rheumatoid arthritis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899526-yes" name="answer-101899526" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899526-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899526-no" name="answer-101899526" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899526-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Systemic lupus erythematosus</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899527-yes" name="answer-101899527" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899527-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899527-no" name="answer-101899527" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899527-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Asthma</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899528-yes" name="answer-101899528" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899528-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899528-no" name="answer-101899528" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899528-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Bronchitis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899529-yes" name="answer-101899529" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899529-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899529-no" name="answer-101899529" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899529-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Emphysema</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899530-yes" name="answer-101899530" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899530-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899530-no" name="answer-101899530" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899530-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Sinus trouble</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899531-yes" name="answer-101899531" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899531-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899531-no" name="answer-101899531" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899531-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Tuberculosis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899532-yes" name="answer-101899532" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899532-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899532-no" name="answer-101899532" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899532-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Cancer/Chemotherapy/Radiation Treatment</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899533-yes" name="answer-101899533" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899533-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899533-no" name="answer-101899533" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899533-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Chest pain upon exertion</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899534-yes" name="answer-101899534" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899534-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899534-no" name="answer-101899534" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899534-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Chronic pain</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899535-yes" name="answer-101899535" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899535-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899535-no" name="answer-101899535" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899535-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Diabetes Type I or II</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899536-yes" name="answer-101899536" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899536-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899536-no" name="answer-101899536" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899536-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Eating disorder</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899537-yes" name="answer-101899537" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899537-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899537-no" name="answer-101899537" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899537-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Malnutrition</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899538-yes" name="answer-101899538" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899538-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899538-no" name="answer-101899538" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899538-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Gastrointestinal disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899539-yes" name="answer-101899539" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899539-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899539-no" name="answer-101899539" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899539-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">G.E. Reflux/persistent heartburn</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899540-yes" name="answer-101899540" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899540-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899540-no" name="answer-101899540" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899540-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Thyroid problems</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899541-yes" name="answer-101899541" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899541-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899541-no" name="answer-101899541" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899541-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Stroke</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899542-yes" name="answer-101899542" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899542-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899542-no" name="answer-101899542" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899542-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Glaucoma</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899543-yes" name="answer-101899543" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899543-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899543-no" name="answer-101899543" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899543-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Hepatitis, jaundice or liver disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899544-yes" name="answer-101899544" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899544-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899544-no" name="answer-101899544" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899544-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Epilepsy</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899545-yes" name="answer-101899545" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899545-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899545-no" name="answer-101899545" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899545-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Fainting spells or seizures</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899546-yes" name="answer-101899546" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899546-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899546-no" name="answer-101899546" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899546-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Neurological disorders</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899547-yes" name="answer-101899547" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899547-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899547-no" name="answer-101899547" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899547-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899547" name="answer-comment-101899547" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Sleep disorder</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899548-yes" name="answer-101899548" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899548-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899548-no" name="answer-101899548" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899548-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Mental health disorders</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899549-yes" name="answer-101899549" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899549-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899549-no" name="answer-101899549" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899549-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899549" name="answer-comment-101899549" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Recurrent infections</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899550-yes" name="answer-101899550" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899550-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899550-no" name="answer-101899550" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899550-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899550" name="answer-comment-101899550" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Kidney problems</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899551-yes" name="answer-101899551" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899551-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899551-no" name="answer-101899551" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899551-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Night sweats</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899552-yes" name="answer-101899552" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899552-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899552-no" name="answer-101899552" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899552-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Osteoporosis</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899553-yes" name="answer-101899553" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899553-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899553-no" name="answer-101899553" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899553-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Persistent swollen glands in neck</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899554-yes" name="answer-101899554" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899554-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899554-no" name="answer-101899554" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899554-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899554" name="answer-comment-101899554" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Severe headaches/migraines</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899555-yes" name="answer-101899555" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899555-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899555-no" name="answer-101899555" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899555-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Severe or rapid weight loss</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899556-yes" name="answer-101899556" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899556-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899556-no" name="answer-101899556" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899556-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Sexually transmitted disease</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899557-yes" name="answer-101899557" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899557-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899557-no" name="answer-101899557" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899557-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Excessive urination</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899558-yes" name="answer-101899558" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899558-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899558-no" name="answer-101899558" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899558-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
</div>
<div class="inner-box" id="section-100365894">
<h3 class="title-h3">Premedication</h3>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899559-yes" name="answer-101899559" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899559-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899559-no" name="answer-101899559" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899559-no" class="b-answers-form__label">NO</label>
</div>
</div>
</div>
<div data-role="editable-comment">
<label for="comment-101899560" class="b-inner-form__label">Name of physician or dentist making recommendation (include phone number)</label>
<input id="comment-101899560" name="comment-101899560" type="text" class="b-inner-form__input b-inner-form__input--full-width">
</div>
<div class="b-answers-form__row mb-1" data-role="radio-button" data-required="">
<span class="b-answers-form__text" data-role="text">Do you have any disease, condition, or problem not listed above that you think I should know about?</span>
<div class="b-answers-form__radios-group">
<div class="b-answers-form__radio-wrap">
<input id="answer-101899561-yes" name="answer-101899561" type="radio" class="default b-answers-form__input" value="Yes">
<label for="answer-101899561-yes" class="b-answers-form__label">YES</label>
</div>
<div class="b-answers-form__radio-wrap">
<input id="answer-101899561-no" name="answer-101899561" type="radio" class="default b-answers-form__input" value="No">
<label for="answer-101899561-no" class="b-answers-form__label">NO</label>
</div>
</div>
<div class="hidden-input-wrap" data-role="comment" style="display: none;">
<input id="answer-comment-101899561" name="answer-comment-101899561" type="text" class="b-inner-form__input b-inner-form__input--padding" placeholder="If yes, please explain">
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<h3 class="title-h3">Signature</h3>
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<input type="text" id="signature-101899562" name="signature-101899562" data-role="value" data-type="text" maxlength="50" class="b-inner-form__input" placeholder="Type Name" autocomplete="">
<span class="validation-message" data-role="validation-message" data-target="signature-101899562"></span>
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