{"id":77030,"date":"2024-06-26T18:14:03","date_gmt":"2024-06-26T18:14:03","guid":{"rendered":"https:\/\/mtctheme.medicaltourismco.com\/?page_id=77030"},"modified":"2024-07-22T07:43:17","modified_gmt":"2024-07-22T07:43:17","slug":"bariatric-questionnaire","status":"publish","type":"page","link":"https:\/\/mtctheme.medicaltourismco.com\/bariatric-questionnaire\/","title":{"rendered":"Bariatric Questionnaire"},"content":{"rendered":"<div class=\"zf-subContWrap zf-topAlign\">\n<div class=\"form-subtitle\">\n<h4 class=\"sec-title\">Personal Information<label class=\"disclaimer\">We do not share this information. Any other disclaimer.<\/label><\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group\">\n<p><input id=\"Name_First\" class=\"text-field-3 w-input\" autocomplete=\"name\" maxlength=\"80\" name=\"Name_First\" type=\"text\" placeholder=\"First Name*\" \/><\/p>\n<p><label>First Name<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group\">\n<p><input id=\"Name_Last\" class=\"text-field-3 w-input\" autocomplete=\"name\" maxlength=\"80\" name=\"Name_Last\" type=\"text\" placeholder=\"Last Name*\" \/><\/p>\n<p><label for=\"Name_Last\">Last Name<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Gender<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Male\" class=\"form-check-input\" name=\"Radio\" type=\"radio\" value=\"Male\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Male\">Male<\/label><\/p>\n<p><input id=\"Female\" class=\"form-check-input\" name=\"Radio\" type=\"radio\" value=\"Female\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Female\">Female<\/label><\/p>\n<p><input id=\"Other\" class=\"form-check-input\" name=\"Radio\" type=\"radio\" value=\"Other\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Other\">Other<\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group\">\n<p><input id=\"Phone\" name=\"PhoneNumber_countrycode\" type=\"text\" value=\"\" placeholder=\"\" \/><\/p>\n<p><!-- <input type=\"text\" compname=\"PhoneNumber\" name=\"PhoneNumber_countrycode\" maxlength=\"20\" checktype=\"c7\" value=\"\" phoneFormat=\"1\" isCountryCodeEnabled=true fieldType=\"11\" valType=\"number\" phoneFormatType=\"1\" placeholder=\"\" \/> --><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"Email\" type=\"text\" placeholder=\"Email*\" \/><\/p>\n<p><label>Email<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group\">\n<p><input class=\"datepicker maxtoday\" max=\"3000-01-01\" maxlength=\"25\" min=\"1900-01-01\" name=\"Date\" type=\"date\" value=\"\" placeholder=\"Date of Birth\" \/><\/p>\n<p><label> Date of Birth<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"Address_City\" type=\"text\" placeholder=\"City*\" \/><\/p>\n<p><label>City<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group\">\n<p><input maxlength=\"255\" name=\"Address_ZipCode\" type=\"text\" placeholder=\"Postal \/ Zip Code\" \/><\/p>\n<p><label for=\"Address_ZipCode\">Postal \/ Zip Code<\/label><\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<h4 class=\"sec-title\">Emergency Contact<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"Name1_First\" type=\"text\" placeholder=\"First Name*\" \/><\/p>\n<p><label>First Name <em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"Name1_Last\" type=\"text\" placeholder=\"Last Name*\" \/><\/p>\n<p><label>Last Name<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"SingleLine5\" type=\"text\" placeholder=\"Relationship*\" \/><\/p>\n<p><label>Relationship<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"Email1\" type=\"text\" placeholder=\"Email*\" \/><\/p>\n<p><label>Email<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input id=\"phone_number1\" maxlength=\"255\" name=\"PhoneNumber1_countrycode\" type=\"text\" placeholder=\"\" \/><\/p>\n<p><label>Telephone No (Home)<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group \">\n<p><input id=\"phone_number2\" maxlength=\"255\" name=\"PhoneNumber2_countrycode\" type=\"text\" placeholder=\"\" \/><\/p>\n<p><label>Telephone No (Business)<em class=\"important\" aria-hidden=\"true\">*<\/em><\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<h4 class=\"sec-title\">Medical<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"SingleLine\" type=\"text\" placeholder=\"Desired Destination\" \/><\/p>\n<p><label>Desired Destination<\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"SingleLine1\" type=\"text\" placeholder=\"Desired Medical Procedure\" \/><\/p>\n<p><label>Desired Medical Procedure<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input class=\"datepicker mintoday\" max=\"3000-01-01\" maxlength=\"255\" min=\"1900-01-01\" name=\"Date1\" type=\"date\" placeholder=\"Proposed Surgery Date\" \/><\/p>\n<p><label>Desired Surgery Date<\/label><\/p>\n<\/div>\n<div class=\"form-check\">\n<p><span>Do you have a passport?:<em class=\"important\" aria-hidden=\"true\">*<\/em><\/span><\/p>\n<p><input id=\"Radio17_1\" class=\"form-check-input\" name=\"Radio17\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio17_1\">Yes<\/label><\/p>\n<p><input id=\"Radio17_2\" class=\"form-check-input\" name=\"Radio17\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio17_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine2\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<h4 class=\"sec-title\">Social Profile<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Your Marital status:<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio1_1\" class=\"form-check-input\" name=\"Radio1\" type=\"radio\" value=\"Married\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio1_1\">Married<\/label><\/p>\n<p><input id=\"Radio1_2\" class=\"form-check-input\" name=\"Radio1\" type=\"radio\" value=\"Single\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio1_2\">Single<\/label><\/p>\n<p><input id=\"Radio1_3\" class=\"form-check-input\" name=\"Radio1\" type=\"radio\" value=\"Divorced\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio1_3\">Divorced<\/label><\/p>\n<p><input id=\"Radio1_4\" class=\"form-check-input\" name=\"Radio1\" type=\"radio\" value=\"Widowed\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio1_4\">Widowed<\/label><\/p>\n<p><input id=\"Radio1_5\" class=\"form-check-input\" name=\"Radio1\" type=\"radio\" value=\"Other\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio1_5\">Other<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"Radio1_allow_others_text\" placeholder=\"other\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p><span>Do you have children?<em class=\"important\" aria-hidden=\"true\">*<\/em><\/span><\/p>\n<p><input id=\"Radio2_1\" class=\"form-check-input\" name=\"Radio2\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio2_1\">Yes<\/label><\/p>\n<p><input id=\"Radio2_2\" class=\"form-check-input\" name=\"Radio2\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio2_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine15\" placeholder=\"please specify their age and number of kids (if applicable)\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Weight History<\/h4>\n<p><label class=\"disclaimer\">Would you please indicate your weight at the following times? Please tell whether you consider your weight was below average, average, above average, or very heavy in relevant boxes.<\/label><\/p>\n<\/div>\n<div style=\"overflow-x: auto;\">\n<table style=\"width: 100%;\" border=\"1\">\n<tbody>\n<tr>\n<td>*W = Weight<\/td>\n<td><b>Below Average<\/b><\/td>\n<td><b>Average Weight<\/b><\/td>\n<td><b>Above Average<\/b><\/td>\n<td><b>Very Heavy<\/b><\/td>\n<\/tr>\n<tr id=\"Radio8\">\n<td>Birth *W<\/td>\n<td><input class=\"form-check-input\" name=\"Radio8\" type=\"radio\" value=\"Below Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio8\" type=\"radio\" value=\"Average Weight\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio8\" type=\"radio\" value=\"Above Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio8\" type=\"radio\" value=\"Very Heavy\" \/><\/td>\n<\/tr>\n<tr id=\"Radio3\">\n<td>*W at beginning of high school (10-12 yrs)<\/td>\n<td><input class=\"form-check-input\" name=\"Radio3\" type=\"radio\" value=\"Below Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio3\" type=\"radio\" value=\"Average Weight\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio3\" type=\"radio\" value=\"Above Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio3\" type=\"radio\" value=\"Very Heavy\" \/><\/td>\n<\/tr>\n<tr id=\"Radio4\">\n<td>*W at end of high school (15-18 years)<\/td>\n<td><input class=\"form-check-input\" name=\"Radio4\" type=\"radio\" value=\"Below Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio4\" type=\"radio\" value=\"Average Weight\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio4\" type=\"radio\" value=\"Above Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio4\" type=\"radio\" value=\"Very Heavy\" \/><\/td>\n<\/tr>\n<tr id=\"Radio5\">\n<td>*W at time of commencing work (21 years)<\/td>\n<td><input class=\"form-check-input\" name=\"Radio5\" type=\"radio\" value=\"Below Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio5\" type=\"radio\" value=\"Average Weight\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio5\" type=\"radio\" value=\"Above Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio5\" type=\"radio\" value=\"Very Heavy\" \/><\/td>\n<\/tr>\n<tr id=\"Radio6\">\n<td>*W at time of marriage (if applicable)<\/td>\n<td><input class=\"form-check-input\" name=\"Radio6\" type=\"radio\" value=\"Below Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio6\" type=\"radio\" value=\"Average Weight\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio6\" type=\"radio\" value=\"Above Average\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Radio6\" type=\"radio\" value=\"Very Heavy\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"two-column\">\n<div>\n<div class=\"two-column two-in-col\">\n<div class=\"gt-form-group cb-form-group name \">\n<p><select name=\"Dropdown\"><option selected=\"selected\" value=\"\">-Select Height (feet)-<\/option><option value=\"4 ft.\">4 ft.<\/option><option value=\"5 ft.\">5 ft.<\/option><option value=\"6 ft.\">6 ft.<\/option><option value=\"7 ft.\">7 ft.<\/option><\/select><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group name\">\n<p><select name=\"Dropdown1\"><option selected=\"selected\" value=\"\">-Select Height (inches)-<\/option><option value=\"0 in.\">0 in.<\/option><option value=\"1 in.\">1 in.<\/option><option value=\"2 in.\">2 in.<\/option><option value=\"3 in.\">3 in.<\/option><option value=\"4 in.\">4 in.<\/option><option value=\"5 in.\">5 in.<\/option><option value=\"6 in.\">6 in.<\/option><option value=\"7 in.\">7 in.<\/option><option value=\"8 in.\">8 in.<\/option><option value=\"9 in.\">9 in.<\/option><option value=\"10 in.\">10 in.<\/option><option value=\"11 in.\">11 in.<\/option><\/select><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"two-column weight-box two-in-col\">\n<div class=\"gt-form-group cb-form-group \">\n<p><input maxlength=\"255\" name=\"SingleLine4\" type=\"text\" placeholder=\"Current Weight\" \/><\/p>\n<p><label>Current Weight<\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group \">\n<p><select name=\"Dropdown3\"><option value=\"LBS\">LBS<\/option><option value=\"KG\">KG<\/option><\/select><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group name\">\n<p>Since when have you been overweight?<\/p>\n<div class=\"gt-form-group cb-form-group name\">\n<p><input maxlength=\"255\" name=\"SingleLine6\" type=\"text\" placeholder=\"Months\" \/><\/p>\n<p><label>Months<\/label><\/p>\n<\/div>\n<\/div>\n<p><!--\n\n\n<div class=\"form-check\">\n\n                         <span>Current Body Shape:<\/span>\n\n<input class=\"form-check-input\" type=\"radio\" name=\"Radio11\" id=\"Radio11_1\" value=\"Apple\">\n\n<label class=\"form-check-label\" for=\"Radio11_1\">Apple<\/label>\n\n<input class=\"form-check-input\" type=\"radio\" name=\"Radio11\" id=\"Radio11_2\" value=\"Pear\">\n\n<label class=\"form-check-label\" for=\"Radio11_2\">Pear<\/label>\n\n<input class=\"form-check-input\" type=\"radio\" name=\"Radio11\" id=\"Radio11_3\" value=\"Other\">\n\n<label class=\"form-check-label\" for=\"Radio11_3\">Other<\/label>\n\n<\/div>\n\n\n--><\/p>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">WEIGHT LOSS HISTORY<\/h4>\n<p><label>PLEASE CHECK THE DIET PROGRAMS THAT APPLY TO YOU and indicate its DURATION<\/label><\/p>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Weight Watchers<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio12_1\" class=\"form-check-input\" name=\"Radio12\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio12_1\">Yes<\/label><\/p>\n<p><input id=\"Radio12_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio12\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio12_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Jenny Craig\/Nutrisystem\/Gloria Marshall etc<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio13_1\" class=\"form-check-input\" name=\"Radio13\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio13_1\">Yes<\/label><\/p>\n<p><input id=\"Radio13_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio13\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio13_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine9\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Appetite suppressants<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio15_1\" class=\"form-check-input\" name=\"Radio15\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio15_1\">Yes<\/label><\/p>\n<p><input id=\"Radio15_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio15\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio15_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine3\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Any other drug treatment<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio16_1\" class=\"form-check-input\" name=\"Radio16\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio16_1\">Yes<\/label><\/p>\n<p><input id=\"Radio16_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio16\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio16_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine4\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Fad diets <em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio14_1\" class=\"form-check-input\" name=\"Radio14\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio14_1\">Yes<\/label><\/p>\n<p><input id=\"Radio14_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio14\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio14_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine2\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Were there any particular events that lead to significant weight gain:<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio18_1\" class=\"form-check-input\" name=\"Radio18\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio18_1\">Yes<\/label><\/p>\n<p><input id=\"Radio18_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio18\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio18_2\">No<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<div class=\"gt-form-group cb-form-group\">\n<p>Details of any other weight loss measures (including surgical)<\/p>\n<p><textarea name=\"MultiLine5\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Family Medical History<\/h4>\n<p><label>Do you have a family history of any of the following and if so, please indicate:<\/label><\/p>\n<\/div>\n<div style=\"overflow-x: auto;\">\n<table style=\"width: 100%;\" border=\"1\">\n<tbody>\n<tr>\n<td><\/td>\n<td><b>Parent<\/b><\/td>\n<td><b> Sibling<br \/>\n\/Child<\/b><\/td>\n<td><b>Other<br \/>\nRelatives<\/b><\/td>\n<td><b>No Family<br \/>\nHistory<\/b><\/td>\n<td><b>Don&#8217;t<br \/>\nKnow<\/b><\/td>\n<\/tr>\n<tr id=\"Diabetes\">\n<td>*Diabetes<\/td>\n<td><input class=\"form-check-input\" name=\"MultipleChoice7\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"MultipleChoice7\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"MultipleChoice7\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"MultipleChoice7\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"MultipleChoice7\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Heart_Disease\">\n<td>*Heart Disease<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Hypertension\">\n<td>*Hypertension<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox1\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox1\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox1\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox1\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox1\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Gout\">\n<td>*Gout<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox2\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox2\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox2\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox2\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox2\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Gallstones\">\n<td>*Gallstones<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox3\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox3\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox3\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox3\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox3\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Obesity\">\n<td>*Obesity<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox4\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox4\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox4\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox4\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox4\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Snoring_Sleep_Apnea\">\n<td>*Snoring<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox5\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox5\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox5\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox5\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox5\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Asthma\">\n<td>*Asthma<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox6\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox6\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox6\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox6\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox6\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Allergies\">\n<td>*Allergies<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox7\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox7\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox7\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox7\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox7\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Hay_Fever\">\n<td>*Hay fever<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox8\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox8\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox8\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox8\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox8\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Dermatitis_Eczema\">\n<td>*Dermatitis<br \/>\n\/Eczema<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox9\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox9\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox9\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox9\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox9\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"High_Cholesterol\">\n<td>*High<br \/>\nCholesterol<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox10\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox10\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox10\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox10\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox10\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Osteoporosis\">\n<td>*Osteoporosis<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox11\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox11\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox11\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox11\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox11\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<tr id=\"Hip_Fractures\">\n<td>*Hip fractures<\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox12\" type=\"checkbox\" value=\"Parent\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox12\" type=\"checkbox\" value=\"Sibling\/Child\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox12\" type=\"checkbox\" value=\"Other Relatives\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox12\" type=\"checkbox\" value=\"No Family History\" \/><\/td>\n<td><input class=\"form-check-input\" name=\"Checkbox12\" type=\"checkbox\" value=\"Don't Know\" \/><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Allergies and Substance Intake<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Recreational drug use<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio19_1\" class=\"form-check-input\" name=\"Radio19\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio19_1\">Yes<\/label><\/p>\n<p><input id=\"Radio19_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio19\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio19_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine1\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Do you smoke?<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio20_1\" class=\"form-check-input\" name=\"Radio20\" type=\"radio\" value=\"Often\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio20_1\">Often<\/label><\/p>\n<p><input id=\"Radio20_2\" class=\"form-check-input\" name=\"Radio20\" type=\"radio\" value=\"Sometimes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio20_2\">Sometimes<\/label><\/p>\n<p><input id=\"Radio20_3\" class=\"form-check-input\" checked=\"checked\" name=\"Radio20\" type=\"radio\" value=\"Never\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio20_3\">Never<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Any allergies<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"MultipleChoice10_1\" class=\"form-check-input\" name=\"MultipleChoice10\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"MultipleChoice10_1\">Yes<\/label><\/p>\n<p><input id=\"MultipleChoice10_2\" class=\"form-check-input\" checked=\"checked\" name=\"MultipleChoice10\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"MultipleChoice10_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine10\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Do you drink alcohol?<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio21_1\" class=\"form-check-input\" name=\"Radio21\" type=\"radio\" value=\"Often\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio21_1\">Often<\/label><\/p>\n<p><input id=\"Radio21_2\" class=\"form-check-input\" name=\"Radio21\" type=\"radio\" value=\"Sometimes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio21_2\">Sometimes<\/label><\/p>\n<p><input id=\"Radio21_3\" class=\"form-check-input\" checked=\"checked\" name=\"Radio21\" type=\"radio\" value=\"Never\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio21_3\">Never<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Surgical History<\/h4>\n<p><label>Please give details of any past operations (especially bariatric)<\/label><\/p>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Any previous surgery<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio22_1\" class=\"form-check-input\" name=\"Radio22\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio22_1\">Yes<\/label><\/p>\n<p><input id=\"Radio22_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio22\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio22_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine12\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p><span>Have you had any infectious diseases before?<\/span><\/p>\n<p><input id=\"Checkbox_1\" class=\"form-check-input\" name=\"MultipleChoice13\" type=\"Checkbox\" value=\"HIV\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Checkbox_1\">HIV<\/label><\/p>\n<p><input id=\"Checkbox_2\" class=\"form-check-input\" name=\"MultipleChoice13\" type=\"Checkbox\" value=\"Streptococcus\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Checkbox_2\">Streptococcus<\/label><\/p>\n<p><input id=\"Checkbox_3\" class=\"form-check-input\" name=\"MultipleChoice13\" type=\"Checkbox\" value=\"Influenza Flu\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Checkbox_3\">Influenza Flu<\/label><\/p>\n<p><input id=\"Checkbox_4\" class=\"form-check-input\" name=\"MultipleChoice13\" type=\"Checkbox\" value=\"Other\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Checkbox_4\">Other<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultipleChoice13_allow_others_text\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Personal medical History<\/h4>\n<p><label>Have you suffered from any of the following?<\/label><\/p>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Diabetes<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio23_1\" class=\"form-check-input\" name=\"Radio23\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio23_1\">Yes<\/label><\/p>\n<p><input id=\"Radio23_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio23\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio23_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine10\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Diabetes while pregnant<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio24_1\" class=\"form-check-input\" name=\"Radio24\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio24_1\">Yes<\/label><\/p>\n<p><input id=\"Radio24_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio24\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio24_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine13\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Asthma<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio25_1\" class=\"form-check-input\" name=\"Radio25\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio25_1\">Yes<\/label><\/p>\n<p><input id=\"Radio25_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio25\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio25_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine14\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Respiratory\/Breathing problems<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio26_1\" class=\"form-check-input\" name=\"Radio26\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio26_1\">Yes<\/label><\/p>\n<p><input id=\"Radio26_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio26\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio26_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine15\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Arthritis or joint pain<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio27_1\" class=\"form-check-input\" name=\"Radio27\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio27_1\">Yes<\/label><\/p>\n<p><input id=\"Radio27_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio27\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio27_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine16\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Kidney or urinary disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio29_1\" class=\"form-check-input\" name=\"Radio29\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio29_1\">Yes<\/label><\/p>\n<p><input id=\"Radio29_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio29\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio29_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine18\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Neurological disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio30_1\" class=\"form-check-input\" name=\"Radio30\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio30_1\">Yes<\/label><\/p>\n<p><input id=\"Radio30_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio30\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio30_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine19\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Psychological\/nervous disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio31_1\" class=\"form-check-input\" name=\"Radio31\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio31_1\">Yes<\/label><\/p>\n<p><input id=\"Radio31_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio31\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio31_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine20\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Gallstones<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio42_1\" class=\"form-check-input\" name=\"Radio42\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio42_1\">Yes<\/label><\/p>\n<p><input id=\"Radio42_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio42\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio42_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine31\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Thrombosis or clotting disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio32_1\" class=\"form-check-input\" name=\"Radio32\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio32_1\">Yes<\/label><\/p>\n<p><input id=\"Radio32_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio32\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio32_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine21\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Gastric or duodenal ulcer<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio33_1\" class=\"form-check-input\" name=\"Radio33\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio33_1\">Yes<\/label><\/p>\n<p><input id=\"Radio33_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio33\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio33_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"MultiLine7\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Hepatitis or liver disease<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio34_1\" class=\"form-check-input\" name=\"Radio34\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio34_1\">Yes<\/label><\/p>\n<p><input id=\"Radio34_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio34\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio34_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine23\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>High blood pressure<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio35_1\" class=\"form-check-input\" name=\"Radio35\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio35_1\">Yes<\/label><\/p>\n<p><input id=\"Radio35_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio35\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio35_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine24\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Heart disease<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio36_1\" class=\"form-check-input\" name=\"Radio36\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio36_1\">Yes<\/label><\/p>\n<p><input id=\"Radio36_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio36\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio36_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine25\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>High cholesterol<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio37_1\" class=\"form-check-input\" name=\"Radio37\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio37_1\">Yes<\/label><\/p>\n<p><input id=\"Radio37_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio37\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio37_2 \">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine26\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Anemia or bleeding disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio38_1\" class=\"form-check-input\" name=\"Radio38\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio38_1\">Yes<\/label><\/p>\n<p><input id=\"Radio38_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio38\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio38_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine28\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Varicose veins or leg swelling<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio39_1\" class=\"form-check-input\" name=\"Radio39\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio39_1\">Yes<\/label><\/p>\n<p><input id=\"Radio39_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio39\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio39_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine29\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Eczema or skin condition<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio40_1\" class=\"form-check-input\" name=\"Radio40\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio40_1\">Yes<\/label><\/p>\n<p><input id=\"Radio40_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio40\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio40_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine30\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Hayfever or Rhinitis<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio41_1\" class=\"form-check-input\" name=\"Radio41\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio41_1\">Yes<\/label><\/p>\n<p><input id=\"Radio41_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio41\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio41_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine27\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Back pain<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio28_1\" class=\"form-check-input\" name=\"Radio28\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio28_1\">Yes<\/label><\/p>\n<p><input id=\"Radio28_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio28\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio28_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine17\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"gt-form-group cb-form-group name\">\n<p><input maxlength=\"255\" name=\"SingleLine32\" type=\"text\" placeholder=\"Any other\" \/><\/p>\n<p><label>Any other<\/label><\/p>\n<\/div>\n<div class=\"gt-form-group cb-form-group name\">\n<p><input maxlength=\"255\" name=\"SingleLine33\" type=\"text\" placeholder=\"List all medications you currently take including dosage\" \/><\/p>\n<p><label>List all medications you currently take including dosage<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Sleep Apnea<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Do you have sleep apnea?<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio43_1\" class=\"form-check-input\" name=\"Radio43\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio43_1\">Yes<\/label><\/p>\n<p><input id=\"Radio43_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio43\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio43_2\">No<\/label><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Do you use CPAP machine??<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio44_1\" class=\"form-check-input\" name=\"Radio44\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio44_1\">Yes<\/label><\/p>\n<p><input id=\"Radio44_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio44\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio44_2\">No<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Medication<\/h4>\n<p><label>Have you ever taken medications for any of the following?<\/label><\/p>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Migraine<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio46_1\" class=\"form-check-input\" name=\"Radio46\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio46_1\">Yes<\/label><\/p>\n<p><input id=\"Radio46_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio46\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio46_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine36\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Weight loss assistance:<\/p>\n<p><input id=\"Radio47_1\" class=\"form-check-input\" name=\"Radio47\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio47_1\">Yes<\/label><\/p>\n<p><input id=\"Radio47_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio47\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio47_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine37\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Epilepsy<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio48_1\" class=\"form-check-input\" name=\"Radio48\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio48_1\">Yes<\/label><\/p>\n<p><input id=\"Radio48_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio48\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio48_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine38\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Asthma or breathing:<\/p>\n<p><input id=\"Radio49_1\" class=\"form-check-input\" name=\"Radio49\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio49_1\">Yes<\/label><\/p>\n<p><input id=\"Radio49_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio49\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio49_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine39\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Psychiatric disorder<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio45_1\" class=\"form-check-input\" name=\"Radio45\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio45_1\">Yes<\/label><\/p>\n<p><input id=\"Radio45_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio45\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio45_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine35\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Hormones, e.g., the pill:<\/p>\n<p><input id=\"Radio50_1\" class=\"form-check-input\" name=\"Radio50\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio50_1\">Yes<\/label><\/p>\n<p><input id=\"Radio50_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio50\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio50_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine40\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>HRT<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio51_1\" class=\"form-check-input\" name=\"Radio51\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio51_1\">Yes<\/label><\/p>\n<p><input id=\"Radio51_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio51\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio51_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine41\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>Cortisone:<\/p>\n<p><input id=\"Radio52_1\" class=\"form-check-input\" name=\"Radio52\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio52_1\">Yes<\/label><\/p>\n<p><input id=\"Radio52_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio52\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio52_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine42\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Blood thinners<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio53_1\" class=\"form-check-input\" name=\"Radio53\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio53_1\">Yes<\/label><\/p>\n<p><input id=\"Radio53_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio53\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio53_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine43\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\"><\/div>\n<\/div>\n<div class=\"one-column\">\n<div class=\"gt-form-group cb-form-group name\">\n<p>Medications taken in the last 12 months (include any dietary supplements, cremes, eye drops, etc.)<\/p>\n<p><textarea maxlength=\"65535\" name=\"SingleLine44\" placeholder=\"Medications\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\"><span><br \/>\nPlease indicate if you take any of the following medications, as taking them before surgery may put your life at risk and cause suspension of the procedure.<\/span><input id=\"MultipleChoice47_1\" class=\"form-check-input\" name=\"MultipleChoice47\" type=\"Checkbox\" value=\"Clopidogrel (Plavix)\" \/><label class=\"form-check-label\" for=\"MultipleChoice47_1\">Clopidogrel (Plavix)<\/label><input id=\"MultipleChoice47_2\" class=\"form-check-input\" name=\"MultipleChoice47\" type=\"Checkbox\" value=\"Enoxaparin (Clexane)\" \/><label class=\"form-check-label\" for=\"MultipleChoice47_2\">Enoxaparin (Clexane)<\/label><\/p>\n<p><input id=\"MultipleChoice47_3\" class=\"form-check-input\" name=\"MultipleChoice47\" type=\"Checkbox\" value=\"Warfarin (Coumadin)\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"MultipleChoice47_3\">Warfarin (Coumadin)<\/label><\/p>\n<p><input id=\"MultipleChoice47_4\" class=\"form-check-input\" name=\"MultipleChoice47\" type=\"Checkbox\" value=\"Acetylsalicylic Acid (Aspirin)\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"MultipleChoice47_4\">Acetylsalicylic Acid (Aspirin)<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Breathing History<\/h4>\n<p><label>Any changes in medication (with or without prescription) must be informed immediately in written form to Medical Tourism Corporation.<\/label><\/p>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Does being at work ever make your chest tight or wheezy?<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio54_1\" class=\"form-check-input\" name=\"Radio54\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio54_1\">Yes<\/label><\/p>\n<p><input id=\"Radio54_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio54\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio54_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine45\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p><span>Have you ever had asthma?<\/span><\/p>\n<p><input id=\"Radio55_1\" class=\"form-check-input\" name=\"Radio55\" type=\"radio\" value=\"Never\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio55_1\">Never<\/label><\/p>\n<p><input id=\"Radio55_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio55\" type=\"radio\" value=\"Currently\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio55_2\">Currently<\/label><\/p>\n<p><input id=\"Radio55_3\" class=\"form-check-input\" checked=\"checked\" name=\"Radio55\" type=\"radio\" value=\"In the past\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio55_3\">In the past<\/label><\/p>\n<p><input id=\"Radio55_4\" class=\"form-check-input\" checked=\"checked\" name=\"Radio55\" type=\"radio\" value=\"Don't know\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio55_4\">Don&#8217;t know<\/label><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">Gastro Esophageal Reflex\/Indigestion<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>History of heartburn, acid reflux or indigestion<em class=\"important\" aria-hidden=\"true\">*<\/em><\/p>\n<p><input id=\"Radio56_1\" class=\"form-check-input\" name=\"Radio56\" type=\"radio\" value=\"Yes\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio56_1\">Yes<\/label><\/p>\n<p><input id=\"Radio56_2\" class=\"form-check-input\" checked=\"checked\" name=\"Radio56\" type=\"radio\" value=\"No\" \/><\/p>\n<p><label class=\"form-check-label\" for=\"Radio56_2\">No<\/label><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine36\" placeholder=\"If yes, details?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<div class=\"form-check\">\n<p>Please list any related treatments<\/p>\n<p><textarea class=\"\" name=\"SingleLine46\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column\">\n<h4 class=\"sec-title\">OB\/GYN<\/h4>\n<\/div>\n<div class=\"two-column\">\n<div class=\"form-check\">\n<p>Pregnancies, births, abortions (if any)<\/p>\n<p><textarea name=\"SingleLine47\"><\/textarea><\/p>\n<\/div>\n<div class=\"form-check\">\n<p>How did you hear about us?<\/p>\n<p><select class=\"zf-form-sBox other-drop\" name=\"Dropdown2\"><option value=\"\">-Select-<\/option><option value=\"Friend \/ Family\">Friend \/ Family<\/option><option value=\"Google \/ Bing\">Google \/ Bing<\/option><option value=\"Facebook\">Facebook<\/option><option value=\"Instagram\">Instagram<\/option><option value=\"TikTok\">TikTok<\/option><option value=\"Youtube\">Youtube<\/option><option value=\"Website\">Website<\/option><option value=\"Other\">Other<\/option><\/select><\/p>\n<p><textarea class=\"optbox\" name=\"SingleLine3\" placeholder=\"How did you hear about us?\"><\/textarea><\/p>\n<\/div>\n<\/div>\n<div class=\"one-column terms\">\n<p>Med Tourism Co LLC <a href=\"https:\/\/mtctheme.medicaltourismco.com\" target=\"_blank\" rel=\"noopener noreferrer\">(www.medicaltourismco.com)<\/a> connects patients to one of the best hospitals in the world. Med Tourism Co LLC does not provide advice on medical treatments nor makes claims or guarantees on the outcome of any medical treatment or surgery. Before making any medical related decision you must thoroughly discuss &amp; seek advice from a qualified medical professional.<\/p>\n<\/div>\n<div class=\"\">\n<p><input id=\"DecisionBox1\" name=\"DecisionBox1\" type=\"checkbox\" \/><\/p>\n<p><label class=\"term-label\" for=\"DecisionBox1\">I have read the above statement, Terms &amp; Conditions &amp; Health Privacy &amp; Confidentiality Statement on the Medical Tourism Corporation Website.<\/label><\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<div class=\"one-column zf-submitColor\">\n<p><button class=\"\">Submit<\/button><\/p>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Personal InformationWe do not share this information. Any other disclaimer. First Name* Last Name* &nbsp; Gender* Male Female Other Email* Date of Birth City* Postal \/ Zip Code &nbsp; Emergency Contact First Name * Last Name* Relationship* Email* Telephone No (Home)* Telephone No (Business)* Medical Desired Destination Desired Medical Procedure Desired Surgery Date Do you [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"templates\/template-page-survey-from.php","meta":{"footnotes":""},"class_list":["post-77030","page","type-page","status-publish","hentry"],"rankMath":{"parentDomain":"medicaltourismco.com","noFollowDomains":[],"noFollowExcludeDomains":[],"noFollowExternalLinks":false,"featuredImageNotice":"The featured image should be at least 200 by 200 pixels to be picked up by Facebook and other social media sites.","pluginReviewed":false,"postSettings":{"linkSuggestions":true,"useFocusKeyword":false},"frontEndScore":false,"postName":"bariatric-questionnaire","permalinkFormat":"https:\/\/mtctheme.medicaltourismco.com\/%pagename%\/","showLockModifiedDate":true,"assessor":{"focusKeywordLink":"https:\/\/mtctheme.medicaltourismco.com\/wp-admin\/edit.php?focus_keyword=%focus_keyword%&post_type=%post_type%","hasTOCPlugin":false,"primaryTaxonomy":false,"serpData":{"title":"Bariatric Questionnaire","description":"Fill our free bariatric questionnaire that helps assess eligibility &amp; benefits of the weight loss surgery. 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