{"id":364,"date":"2017-04-24T07:50:18","date_gmt":"2017-04-24T07:50:18","guid":{"rendered":"http:\/\/www.49themes.com\/demos\/chiropractorwp\/?page_id=364"},"modified":"2022-02-05T18:50:56","modified_gmt":"2022-02-05T18:50:56","slug":"become-a-patient","status":"publish","type":"page","link":"https:\/\/chirocarelex.com\/index.php\/become-a-patient\/","title":{"rendered":"Become a Patient"},"content":{"rendered":"<p>[vc_row el_class=&#8221;appointmentDesign&#8221;][vc_column][vc_row_inner][vc_column_inner][vc_column_text]<\/p>\n<div style=\"font-size: 20px;\">\n<p>Thank you for choosing Chiropractic Care of Lexington! Please complete the form and we will be in contact with you within one business day to schedule your appointment time. We look forward to meeting you!<\/p>\n<\/div>\n<p>[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][vc_column_text]<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1043\"><form id=\"wpforms-form-1043\" class=\"wpforms-validate wpforms-form\" data-formid=\"1043\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/364\" data-token=\"e4a3d1677e8e780caee9d8b43c39b073\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" data-page-2-title=\"Insurance\" data-page-3-title=\"Info about You\" data-page-4-title=\"Symptoms\"><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 4<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:25%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-1043-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><\/div><div id=\"wpforms-1043-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_0\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-1043-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-1043-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-fifth\"><input type=\"text\" id=\"wpforms-1043-field_0-middle\" class=\"wpforms-field-name-middle\" name=\"wpforms[fields][0][middle]\" ><label for=\"wpforms-1043-field_0-middle\" class=\"wpforms-field-sublabel after \">Middle<\/label><\/div><div class=\"wpforms-field-row-block wpforms-two-fifths\"><input type=\"text\" id=\"wpforms-1043-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-1043-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-1043-field_22-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_22\">Birthday <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1043-field_22\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][22][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1043-field_24-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half wpforms-first\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_24\">Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1043-field_24\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-1043-field_23-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_23\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1043-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required><\/div><div id=\"wpforms-1043-field_25-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_25\">Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-1043-field_25\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][25][address1]\" required><label for=\"wpforms-1043-field_25\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-1043-field_25-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][25][address2]\" ><label for=\"wpforms-1043-field_25-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1043-field_25-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][25][city]\" required><label for=\"wpforms-1043-field_25-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1043-field_25-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][25][state]\" required><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-1043-field_25-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1043-field_25-postal\" class=\"wpforms-field-address-postal wpforms-field-required wpforms-masked-input\" data-inputmask-mask=\"99999[-9999]\" data-inputmask-greedy=\"false\" data-rule-empty-blanks=\"1\" name=\"wpforms[fields][25][postal]\" required><label for=\"wpforms-1043-field_25-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-1043-field_26-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_26\">Are you...<\/label><ul id=\"wpforms-1043-field_26\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_1\" name=\"wpforms[fields][26][]\" value=\"A minor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_1\">A minor<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_2\" name=\"wpforms[fields][26][]\" value=\"Single\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_2\">Single<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_8\" name=\"wpforms[fields][26][]\" value=\"Married\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_8\">Married<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_7\" name=\"wpforms[fields][26][]\" value=\"Divorced\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_7\">Divorced<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_6\" name=\"wpforms[fields][26][]\" value=\"Widowed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_6\">Widowed<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_26_5\" name=\"wpforms[fields][26][]\" value=\"Seperated\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_26_5\">Seperated<\/label><\/li><\/ul><\/div><div id=\"wpforms-1043-field_27-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_27\">Spouse \/ Guardian Name<\/label><input type=\"text\" id=\"wpforms-1043-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/div><div id=\"wpforms-1043-field_28-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_28\">Spouse \/ Guardian Phone<\/label><input type=\"tel\" id=\"wpforms-1043-field_28\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][28]\" ><\/div><div id=\"wpforms-1043-field_29-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_29\">Emergency Contact Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1043-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required><\/div><div id=\"wpforms-1043-field_30-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_30\">Emergency Contact Phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1043-field_30\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][30]\" required><\/div><div id=\"wpforms-1043-field_3-container\" class=\"wpforms-field wpforms-field-pagebreak test\" data-field-id=\"3\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"1043\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  test\" style=\"display:none;\"><div id=\"wpforms-1043-field_32-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_32\">Do you have Health Insurance? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-1043-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" required=\"required\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-1043-field_33-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_33\">Insurance Company<\/label><input type=\"text\" id=\"wpforms-1043-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-1043-field_34-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_34\">Name of Insured<\/label><input type=\"text\" id=\"wpforms-1043-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/div><div id=\"wpforms-1043-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_35\">ID\/Policy Number<\/label><input type=\"text\" id=\"wpforms-1043-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-1043-field_36-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_36\">Group Number<\/label><input type=\"text\" id=\"wpforms-1043-field_36\" class=\"wpforms-field-medium\" name=\"wpforms[fields][36]\" ><\/div><div id=\"wpforms-1043-field_37-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_37\">Do you have Secondary Insurance?<\/label><select id=\"wpforms-1043-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_38\">Secondary Insurance Company<\/label><input type=\"text\" id=\"wpforms-1043-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" ><\/div><div id=\"wpforms-1043-field_39-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_39\">Name of Secondary Insured<\/label><input type=\"text\" id=\"wpforms-1043-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-1043-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_40\">Secondary ID\/Policy Number<\/label><input type=\"text\" id=\"wpforms-1043-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" ><\/div><div id=\"wpforms-1043-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_41\">Secondary Group Number<\/label><input type=\"text\" id=\"wpforms-1043-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-1043-field_6-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"6\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"2\" data-formid=\"1043\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"1043\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" style=\"display:none;\"><div id=\"wpforms-1043-field_42-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-classic\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_42\">Have you seen a Chiropractor Before?<\/label><select id=\"wpforms-1043-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_43-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-classic\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_43\">Do you know what we do?<\/label><select id=\"wpforms-1043-field_43\" class=\"wpforms-field-medium\" name=\"wpforms[fields][43]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_44-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_44\">Is this visit the result of a work related accident or an auto accident?<\/label><select id=\"wpforms-1043-field_44\" class=\"wpforms-field-medium\" name=\"wpforms[fields][44]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_47-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_47\">Were you referred to us?<\/label><select id=\"wpforms-1043-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_46-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_46\">Who referred you to us?<\/label><input type=\"text\" id=\"wpforms-1043-field_46\" class=\"wpforms-field-medium\" name=\"wpforms[fields][46]\" ><\/div><div id=\"wpforms-1043-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_48\">Primary Care Physician (PCP)<\/label><input type=\"text\" id=\"wpforms-1043-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" ><\/div><div id=\"wpforms-1043-field_49-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_49\">PCP Phone<\/label><input type=\"tel\" id=\"wpforms-1043-field_49\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][49]\" ><\/div><div id=\"wpforms-1043-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_50\">When did you last see a chiropractor?<\/label><input type=\"text\" id=\"wpforms-1043-field_50\" class=\"wpforms-field-medium\" name=\"wpforms[fields][50]\" ><\/div><div id=\"wpforms-1043-field_51-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_51\">Are you Pregnant?<\/label><select id=\"wpforms-1043-field_51\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][51]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>No<\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-1043-field_52-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_52\">Date of last Menstrual Period?<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1043-field_52\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][52][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1043-field_53-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_53\">When did your symptoms start?<\/label><input type=\"text\" id=\"wpforms-1043-field_53\" class=\"wpforms-field-medium\" name=\"wpforms[fields][53]\" ><\/div><div id=\"wpforms-1043-field_54-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_54\">How did your symptoms begin?<\/label><textarea id=\"wpforms-1043-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" ><\/textarea><\/div><div id=\"wpforms-1043-field_55-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_55\">How often do you experience your symptoms?<\/label><select id=\"wpforms-1043-field_55\" class=\"wpforms-field-medium\" name=\"wpforms[fields][55]\"><option value=\"Constantly (76%-100% of the day)\" >Constantly (76%-100% of the day)<\/option><option value=\"Frequently (51%-75% of the day)\" >Frequently (51%-75% of the day)<\/option><option value=\"Occasionally (26%-50% of the day)\" >Occasionally (26%-50% of the day)<\/option><option value=\"Intermittently (0%-25% of the day)\" >Intermittently (0%-25% of the day)<\/option><\/select><\/div><div id=\"wpforms-1043-field_56-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_56\">What describes the nature of your symptoms?<\/label><select id=\"wpforms-1043-field_56\" class=\"wpforms-field-medium\" name=\"wpforms[fields][56]\"><option value=\"Dull Ache\" >Dull Ache<\/option><option value=\"Numb\" >Numb<\/option><option value=\"Shooting\" >Shooting<\/option><option value=\"Burning\" >Burning<\/option><option value=\"Tingling\" >Tingling<\/option><\/select><\/div><div id=\"wpforms-1043-field_58-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_58\">How are your symptoms changing?<\/label><select id=\"wpforms-1043-field_58\" class=\"wpforms-field-medium\" name=\"wpforms[fields][58]\"><option value=\"Getting Better\" >Getting Better<\/option><option value=\"Not Changing\" >Not Changing<\/option><option value=\"Getting worse\" >Getting worse<\/option><\/select><\/div><div id=\"wpforms-1043-field_59-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_59\">How much has the pain interfered with your normal work (including both work outside the home, and housework)<\/label><select id=\"wpforms-1043-field_59\" class=\"wpforms-field-medium\" name=\"wpforms[fields][59]\"><option value=\"Not at all\" >Not at all<\/option><option value=\"A little bit\" >A little bit<\/option><option value=\"Moderately\" >Moderately<\/option><option value=\"Quite a bit\" >Quite a bit<\/option><option value=\"Extremely\" >Extremely<\/option><\/select><\/div><div id=\"wpforms-1043-field_60-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_60\">How much of the time has your condition interfered with your social activities?<\/label><select id=\"wpforms-1043-field_60\" class=\"wpforms-field-medium\" name=\"wpforms[fields][60]\"><option value=\"Not at all\" >Not at all<\/option><option value=\"A little bit\" >A little bit<\/option><option value=\"Moderately\" >Moderately<\/option><option value=\"Quite a bit\" >Quite a bit<\/option><option value=\"Extremely\" >Extremely<\/option><\/select><\/div><div id=\"wpforms-1043-field_61-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_61\">In general how would you say your health right now is?<\/label><select id=\"wpforms-1043-field_61\" class=\"wpforms-field-medium\" name=\"wpforms[fields][61]\"><option value=\"Excellent\" >Excellent<\/option><option value=\"Very Good\" >Very Good<\/option><option value=\"Good\" >Good<\/option><option value=\"Fair\" >Fair<\/option><option value=\"Poor\" >Poor<\/option><\/select><\/div><div id=\"wpforms-1043-field_62-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_62\">Who have you seen for your symptoms?<\/label><select id=\"wpforms-1043-field_62\" class=\"wpforms-field-medium\" name=\"wpforms[fields][62]\"><option value=\"No One\" >No One<\/option><option value=\"Other Chiropractor\" >Other Chiropractor<\/option><option value=\"Medical Doctor\" >Medical Doctor<\/option><option value=\"Physical Therapist\" >Physical Therapist<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1043-field_63-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_63\">What treatment did you receive and when?<\/label><textarea id=\"wpforms-1043-field_63\" class=\"wpforms-field-medium\" name=\"wpforms[fields][63]\" ><\/textarea><\/div><div id=\"wpforms-1043-field_64-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_64\">What test have you had for your symptoms?<\/label><select id=\"wpforms-1043-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\"><option value=\"None\" >None<\/option><option value=\"X-Rays\" >X-Rays<\/option><option value=\"CT Scan\" >CT Scan<\/option><option value=\"MRI\" >MRI<\/option><\/select><\/div><div id=\"wpforms-1043-field_65-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_65\">When were they performed?<\/label><textarea id=\"wpforms-1043-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\" placeholder=\"X-rays Date: ... MRI Date: ...\" ><\/textarea><\/div><div id=\"wpforms-1043-field_66-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_66\">Have you had similar symptoms in the past?<\/label><select id=\"wpforms-1043-field_66\" class=\"wpforms-field-medium\" name=\"wpforms[fields][66]\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-1043-field_67-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_67\">If you have received treatment in the past for the same or similar symptoms, who did you see?<\/label><select id=\"wpforms-1043-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\"><option value=\"None\" >None<\/option><option value=\"This Office\" >This Office<\/option><option value=\"Another Chiropractor\" >Another Chiropractor<\/option><option value=\"Medical Doctor\" >Medical Doctor<\/option><option value=\"Physical Therapist\" >Physical Therapist<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1043-field_68-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_68\">What is your Occupation?<\/label><select id=\"wpforms-1043-field_68\" class=\"wpforms-field-medium\" name=\"wpforms[fields][68]\"><option value=\"Professional\/Executive\" >Professional\/Executive<\/option><option value=\"White Collar\/Secretarial\" >White Collar\/Secretarial<\/option><option value=\"Tradesperson\" >Tradesperson<\/option><option value=\"Homemaker\" >Homemaker<\/option><option value=\"FT student\" >FT student<\/option><option value=\"Retired\" >Retired<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1043-field_69-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_69\">if you are not retired, a homemaker, or a student, what is your current work status?<\/label><select id=\"wpforms-1043-field_69\" class=\"wpforms-field-medium\" name=\"wpforms[fields][69]\"><option value=\"Full Time\" >Full Time<\/option><option value=\"Part Time\" >Part Time<\/option><option value=\"Self-Employed\" >Self-Employed<\/option><option value=\"Unemployed\" >Unemployed<\/option><option value=\"Off Work\" >Off Work<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1043-field_70-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_70\">What type of exercise do you perform?<\/label><select id=\"wpforms-1043-field_70\" class=\"wpforms-field-medium\" name=\"wpforms[fields][70]\"><option value=\"None\" >None<\/option><option value=\"Light\" >Light<\/option><option value=\"Moderate\" >Moderate<\/option><option value=\"Strenuous\" >Strenuous<\/option><\/select><\/div><div id=\"wpforms-1043-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_71\">Height<\/label><input type=\"text\" id=\"wpforms-1043-field_71\" class=\"wpforms-field-medium\" name=\"wpforms[fields][71]\" placeholder=\"ft\/in\" ><\/div><div id=\"wpforms-1043-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_72\">Weight<\/label><input type=\"text\" id=\"wpforms-1043-field_72\" class=\"wpforms-field-medium\" name=\"wpforms[fields][72]\" placeholder=\"lbs\" ><\/div><div id=\"wpforms-1043-field_73-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"73\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"3\" data-formid=\"1043\" disabled>Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"1043\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last \" style=\"display:none;\"><div id=\"wpforms-1043-field_75-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"75\"><div id=\"wpforms-1043-field_75\"><p>For each condition listed below, leave blank if never, otherwise select past or present.<\/p><\/div><\/div><div id=\"wpforms-1043-field_74-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_74\">Headaches<\/label><select id=\"wpforms-1043-field_74\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][74]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_76-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_76\">Neck Pain<\/label><select id=\"wpforms-1043-field_76\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][76]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_77-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_77\">Upper Back Pain<\/label><select id=\"wpforms-1043-field_77\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][77]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_78-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_78\">Mid Back Pain<\/label><select id=\"wpforms-1043-field_78\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][78]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_79-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_79\">Low Back Pain<\/label><select id=\"wpforms-1043-field_79\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][79]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_80-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_80\">Shoulder Pain<\/label><select id=\"wpforms-1043-field_80\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][80]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_84-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_84\">Elbow\/Upper Arm Pain<\/label><select id=\"wpforms-1043-field_84\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][84]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_81-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"81\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_81\">Wrist Pain<\/label><select id=\"wpforms-1043-field_81\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][81]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_85-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_85\">Hand Pain<\/label><select id=\"wpforms-1043-field_85\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][85]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_82-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_82\">Hip\/Upper Leg Pain<\/label><select id=\"wpforms-1043-field_82\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][82]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_86-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_86\">Knee\/Lower Leg Pain<\/label><select id=\"wpforms-1043-field_86\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][86]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_83-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_83\">Ankle\/Foot Pain<\/label><select id=\"wpforms-1043-field_83\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][83]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_87-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_87\">Jaw Pain<\/label><select id=\"wpforms-1043-field_87\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][87]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_90-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_90\">Joint Swelling\/Stiffness<\/label><select id=\"wpforms-1043-field_90\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][90]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_88-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_88\">Arthritis<\/label><select id=\"wpforms-1043-field_88\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][88]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_91-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_91\">Rheumatoid Arthritis<\/label><select id=\"wpforms-1043-field_91\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][91]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_89-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"89\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_89\">General Fatigue<\/label><select id=\"wpforms-1043-field_89\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][89]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_92-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_92\">Muscular Incoordination<\/label><select id=\"wpforms-1043-field_92\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][92]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_93-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_93\">Visual Disturbances<\/label><select id=\"wpforms-1043-field_93\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][93]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_98-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_98\">Dizziness<\/label><select id=\"wpforms-1043-field_98\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][98]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_94-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"94\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_94\">High Blood Pressure<\/label><select id=\"wpforms-1043-field_94\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][94]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_99-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_99\">Heart Attack<\/label><select id=\"wpforms-1043-field_99\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][99]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_95-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_95\">Chest Pains<\/label><select id=\"wpforms-1043-field_95\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][95]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_100-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_100\">Stroke<\/label><select id=\"wpforms-1043-field_100\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][100]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_96-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_96\">Angina<\/label><select id=\"wpforms-1043-field_96\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][96]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_101-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_101\">Kidney Stones<\/label><select id=\"wpforms-1043-field_101\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][101]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_97-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_97\">Kidney Disorders<\/label><select id=\"wpforms-1043-field_97\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][97]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_105-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"105\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_105\">Bladder Infection<\/label><select id=\"wpforms-1043-field_105\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][105]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_102-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_102\">Painful Urination<\/label><select id=\"wpforms-1043-field_102\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][102]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_106-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"106\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_106\">Loss of Bladder Control<\/label><select id=\"wpforms-1043-field_106\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][106]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_103-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_103\">Prostate Problems<\/label><select id=\"wpforms-1043-field_103\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][103]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_107-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"107\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_107\">Abnormal Weight Gain\/Loss<\/label><select id=\"wpforms-1043-field_107\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][107]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_104-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_104\">Loss of Appetite<\/label><select id=\"wpforms-1043-field_104\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][104]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_109-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"109\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_109\">Abdominal Pain<\/label><select id=\"wpforms-1043-field_109\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][109]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_112-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"112\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_112\">Ulcer<\/label><select id=\"wpforms-1043-field_112\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][112]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_110-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_110\">Hepatitis<\/label><select id=\"wpforms-1043-field_110\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][110]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_113-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"113\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_113\">Liver\/Gall Bladder Disorder<\/label><select id=\"wpforms-1043-field_113\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][113]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_111-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"111\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_111\">Cancer<\/label><select id=\"wpforms-1043-field_111\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][111]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_114-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"114\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_114\">Tumor<\/label><select id=\"wpforms-1043-field_114\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][114]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_115-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"115\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_115\">Asthma<\/label><select id=\"wpforms-1043-field_115\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][115]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_118-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_118\">Chronic Sinusitis<\/label><select id=\"wpforms-1043-field_118\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][118]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_116-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"116\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_116\">Diabetes<\/label><select id=\"wpforms-1043-field_116\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][116]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_119-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"119\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_119\">Excessive Thirst<\/label><select id=\"wpforms-1043-field_119\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][119]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_117-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"117\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_117\">Frequent Urination<\/label><select id=\"wpforms-1043-field_117\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][117]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_120-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_120\">Smoking\/Use of Tobacco Products<\/label><select id=\"wpforms-1043-field_120\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][120]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_121-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"121\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_121\">Drug\/Alcohol Dependence<\/label><select id=\"wpforms-1043-field_121\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][121]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_124-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"124\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_124\">Allergies<\/label><select id=\"wpforms-1043-field_124\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][124]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_122-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"122\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_122\">Depression<\/label><select id=\"wpforms-1043-field_122\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][122]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_125-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"125\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_125\">Systemic Lupus<\/label><select id=\"wpforms-1043-field_125\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][125]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_123-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"123\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_123\">Epilepsy<\/label><select id=\"wpforms-1043-field_123\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][123]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_126-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_126\">Dermatitis\/Eczema\/Rash<\/label><select id=\"wpforms-1043-field_126\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][126]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_129-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"129\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_129\">HIV\/AIDS<\/label><select id=\"wpforms-1043-field_129\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][129]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_127-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"127\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_127\">Birth Control<\/label><select id=\"wpforms-1043-field_127\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][127]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_130-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-modern\" data-field-id=\"130\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_130\">Hormonal Repleacement<\/label><select id=\"wpforms-1043-field_130\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][130]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_128-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-modern\" data-field-id=\"128\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_128\">Pregnancy<\/label><select id=\"wpforms-1043-field_128\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][128]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>None<\/option><option value=\"Past\" >Past<\/option><option value=\"Present\" >Present<\/option><\/select><\/div><div id=\"wpforms-1043-field_131-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"131\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_131\">Other Health Problems\/Issues<\/label><textarea id=\"wpforms-1043-field_131\" class=\"wpforms-field-medium\" name=\"wpforms[fields][131]\" ><\/textarea><\/div><div id=\"wpforms-1043-field_132-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"132\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_132\">Please indicate if an immediate family member has had any of the following...<\/label><ul id=\"wpforms-1043-field_132\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_1\" name=\"wpforms[fields][132][]\" value=\"Rheumatoid Arthritis\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_1\">Rheumatoid Arthritis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_2\" name=\"wpforms[fields][132][]\" value=\"Heart Problem\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_2\">Heart Problem<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_3\" name=\"wpforms[fields][132][]\" value=\"Diabetes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_3\">Diabetes<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_4\" name=\"wpforms[fields][132][]\" value=\"Cancer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_4\">Cancer<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_5\" name=\"wpforms[fields][132][]\" value=\"Lupus\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_5\">Lupus<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1043-field_132_6\" name=\"wpforms[fields][132][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1043-field_132_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1043-field_133-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"133\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_133\">List all prescription and over-the-counter medications and nutrirional\/herbal supplements you are taking:<\/label><textarea id=\"wpforms-1043-field_133\" class=\"wpforms-field-medium\" name=\"wpforms[fields][133]\" ><\/textarea><\/div><div id=\"wpforms-1043-field_134-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"134\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_134\">List all surgical procedures you have had and times you have been hospitalized:<\/label><textarea id=\"wpforms-1043-field_134\" class=\"wpforms-field-medium\" name=\"wpforms[fields][134]\" ><\/textarea><\/div><div id=\"wpforms-1043-field_135-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"135\"><label class=\"wpforms-field-label\" for=\"wpforms-1043-field_135\">Enter your name for consent to treatment <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1043-field_135\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][135]\" placeholder=\"Full Name\" required><\/div><div id=\"wpforms-1043-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"1043\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-1043\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row el_class=&#8221;appointmentDesign&#8221;][vc_column][vc_row_inner][vc_column_inner][vc_column_text] Thank you for choosing Chiropractic Care of Lexington! Please complete the form and we will be in contact with you within one business day to schedule your appointment time. We look forward to meeting you! 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