{"id":17493,"date":"2025-04-09T16:02:21","date_gmt":"2025-04-09T14:02:21","guid":{"rendered":"https:\/\/gezonde-darmflora.nl\/?page_id=17493"},"modified":"2025-04-18T10:52:41","modified_gmt":"2025-04-18T08:52:41","slug":"donor-questionnaire","status":"publish","type":"page","link":"https:\/\/gezonde-darmflora.nl\/en\/donor-questionnaire\/","title":{"rendered":"Donor questionnaire"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=&#8221;stretch_row_content_no_spaces&#8221;][vc_column]\r\n    <div class=\"page-title\">\r\n        <div class=\"container\">\r\n            <div class=\"row\">\r\n                <div class=\"col\">\r\n                    <h1>Donor questionnaire<\/h1>\r\n                <\/div>\r\n            <\/div>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    [\/vc_column][\/vc_row][vc_row][vc_column]<style id=\"wpforms-css-vars-17495\">\n\t\t\t\t#wpforms-17495 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-17495\"><form id=\"wpforms-form-17495\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"17495\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/17493\" data-token=\"557913c33c7ff6aff6f426830f62e99a\" data-token-time=\"1776698660\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#066aab\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"12\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/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 12<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:8.3333333333333%;background-color:#066aab\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-17495-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"1\"><div id=\"wpforms-17495-field_1\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_1-error\"><h4>Personal data<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_152-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"152\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-17495-field_152\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][152][first]\" aria-errormessage=\"wpforms-17495-field_152-error\" required><label for=\"wpforms-17495-field_152\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-17495-field_152-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][152][last]\" aria-errormessage=\"wpforms-17495-field_152-last-error\" required><label for=\"wpforms-17495-field_152-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-17495-field_2-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_2\">Date of birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17495-field_2\" 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][2][date]\" aria-errormessage=\"wpforms-17495-field_2-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17495-field_153-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_153\">E-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-17495-field_153\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][153]\" spellcheck=\"false\" aria-errormessage=\"wpforms-17495-field_153-error\" required><\/div><div id=\"wpforms-17495-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_4\">Mobile phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-17495-field_4-error\" required><\/div><div id=\"wpforms-17495-field_154-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"154\"><fieldset><legend class=\"wpforms-field-label\">Address<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-17495-field_154\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][154][address1]\" aria-errormessage=\"wpforms-17495-field_154-error\" ><label for=\"wpforms-17495-field_154\" class=\"wpforms-field-sublabel after\">Address Line 1<\/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-17495-field_154-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][154][city]\" aria-errormessage=\"wpforms-17495-field_154-city-error\" ><label for=\"wpforms-17495-field_154-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-17495-field_154-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][154][state]\" aria-errormessage=\"wpforms-17495-field_154-state-error\" ><label for=\"wpforms-17495-field_154-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/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-17495-field_154-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][154][postal]\" aria-errormessage=\"wpforms-17495-field_154-postal-error\" ><label for=\"wpforms-17495-field_154-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-17495-field_154-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][154][country]\" aria-errormessage=\"wpforms-17495-field_154-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>--- Select country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-17495-field_154-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-17495-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_6_1\" name=\"wpforms[fields][6]\" value=\"Male\" aria-errormessage=\"wpforms-17495-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_6_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_6_2\" name=\"wpforms[fields][6]\" value=\"Female\" aria-errormessage=\"wpforms-17495-field_6_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_6_2\">Female<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_7-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"7\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-17495-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><\/div><div id=\"wpforms-17495-field_10-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"10\"><div id=\"wpforms-17495-field_10\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_10-error\"><h4>Body Data and General Health<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_11\">What is your weight? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-17495-field_11-error\" aria-describedby=\"wpforms-17495-field_11-description\" required><div id=\"wpforms-17495-field_11-description\" class=\"wpforms-field-description\">In kilo<\/div><\/div><div id=\"wpforms-17495-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_12\">What is your height? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-17495-field_12-error\" aria-describedby=\"wpforms-17495-field_12-description\" required><div id=\"wpforms-17495-field_12-description\" class=\"wpforms-field-description\">In CM<\/div><\/div><div id=\"wpforms-17495-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_13\">Wat is your BMI? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-17495-field_13-error\" aria-describedby=\"wpforms-17495-field_13-description\" required><div id=\"wpforms-17495-field_13-description\" class=\"wpforms-field-description\">In cm\/kg2<\/div><\/div><div id=\"wpforms-17495-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_14\">What is your profession\/study? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-17495-field_14-error\" required><\/div><div id=\"wpforms-17495-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_15\">What is your education level? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-17495-field_15-error\" required><\/div><div id=\"wpforms-17495-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_16\">What is your family composition? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-17495-field_16-error\" required><\/div><div id=\"wpforms-17495-field_17-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"17\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-17495-field_18-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"18\"><div id=\"wpforms-17495-field_18\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_18-error\"><h4>Medical History<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Were you born naturally or by caesarean section? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_19_1\" name=\"wpforms[fields][19]\" value=\"Naturally\" aria-errormessage=\"wpforms-17495-field_19_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_19_1\">Naturally<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_19_2\" name=\"wpforms[fields][19]\" value=\"Caesarean section\" aria-errormessage=\"wpforms-17495-field_19_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_19_2\">Caesarean section<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_20-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Do you have any children?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_20_1\" name=\"wpforms[fields][20]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_20_2\" name=\"wpforms[fields][20]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_20_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been rejected during an examination (as a donor or otherwise)?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_22_1\" name=\"wpforms[fields][22]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_22_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_22_2\" name=\"wpforms[fields][22]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_22_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_22_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_23-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"23\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_23\">Why <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17495-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-17495-field_23-error\" required><\/textarea><\/div><div id=\"wpforms-17495-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Have you ever donated blood?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_24_1\" name=\"wpforms[fields][24]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_24_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_24_2\" name=\"wpforms[fields][24]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_24_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_24_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_27-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"27\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_27\">If so when was the last time? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17495-field_27\" 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][27][date]\" aria-errormessage=\"wpforms-17495-field_27-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17495-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been to a specialist (doctor in the hospital)?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_28_1\" name=\"wpforms[fields][28]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_28_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_28_2\" name=\"wpforms[fields][28]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_28_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_29-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_29\">When? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17495-field_29\" 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][29][date]\" aria-errormessage=\"wpforms-17495-field_29-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17495-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">Are you vaccinated for covid-19? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_30_1\" name=\"wpforms[fields][30]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_30_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_30_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_30_2\" name=\"wpforms[fields][30]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_30_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_30_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_31-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_31\">How many times? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_31-error\" required><\/div><div id=\"wpforms-17495-field_32-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_32\">Which manufacturer? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-17495-field_32-error\" required><\/div><div id=\"wpforms-17495-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Do you take medicines?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_33_1\" name=\"wpforms[fields][33]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_33_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_33_2\" name=\"wpforms[fields][33]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_33_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_33_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_34-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_34\">If so, what medications did you receive? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-17495-field_34-error\" required><\/div><div id=\"wpforms-17495-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_35\">In what year was this treatment started?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_35\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-17495-field_35-error\" required><\/div><div id=\"wpforms-17495-field_36-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Have you been depressed in the past?        <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_36\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_36_1\" name=\"wpforms[fields][36]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_36_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_36_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_36_2\" name=\"wpforms[fields][36]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_36_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_36_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_37-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_37\">When did this start and for how long?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_37\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-17495-field_37-error\" required><\/div><div id=\"wpforms-17495-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_38\">Have you taken any medication for this?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_38\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-17495-field_38-error\" required><\/div><div id=\"wpforms-17495-field_39-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"39\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-17495-field_40-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"40\"><div id=\"wpforms-17495-field_40\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_40-error\"><h4>Chronic Disorders and Heredity<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Have you been treated for autism?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_41_1\" name=\"wpforms[fields][41]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_41_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_41_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_41_2\" name=\"wpforms[fields][41]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_41_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_41_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_42-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been tested for diabetes?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_42_1\" name=\"wpforms[fields][42]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_42_2\" name=\"wpforms[fields][42]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_42_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_42_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_43-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_43\">What was the result? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-17495-field_43-error\" required><\/div><div id=\"wpforms-17495-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Does diabetes run in the family?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_44_1\" name=\"wpforms[fields][44]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_44_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_44_2\" name=\"wpforms[fields][44]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_44_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">Is there a family history of schizophrenia\/bipolar or anxiety disorders?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_45_1\" name=\"wpforms[fields][45]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_45_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_45_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_45_2\" name=\"wpforms[fields][45]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_45_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_45_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_46-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">Does Creuzfeldt Jakob disease run in your family?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_46_1\" name=\"wpforms[fields][46]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_46_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_46_2\" name=\"wpforms[fields][46]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_46_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><fieldset><legend class=\"wpforms-field-label\">Does dementia run in your family before the age of 60?                <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_47_1\" name=\"wpforms[fields][47]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_47_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_47_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_47_2\" name=\"wpforms[fields][47]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_47_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_47_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_48-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"48\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"4\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-17495-field_49-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"49\"><div id=\"wpforms-17495-field_49\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_49-error\"><h4>Environment and Risk Areas<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_50-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Do you have any pets? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_50_1\" name=\"wpforms[fields][50]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_50_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_50_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_50_2\" name=\"wpforms[fields][50]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_50_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_50_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_51-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">Were you born in a country outside Europe  or have you lived longer in a country outside Europe for 5 years?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_51_1\" name=\"wpforms[fields][51]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_51_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_51_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_51_2\" name=\"wpforms[fields][51]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_51_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_51_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_52\">Where and when? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_52\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-17495-field_52-error\" required><\/div><div id=\"wpforms-17495-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Did you stay in the UK for more than 6 months between 1980 and 1996 combined? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_53_1\" name=\"wpforms[fields][53]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_53_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_53_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_53_2\" name=\"wpforms[fields][53]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_53_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_53_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">Have you been to the tropics in the last two years? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_54_1\" name=\"wpforms[fields][54]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_54_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_54_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_54_2\" name=\"wpforms[fields][54]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_54_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_54_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_55-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_55\">Where and in what year? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-17495-field_55-error\" required><\/div><div id=\"wpforms-17495-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had malaria?         <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_56_1\" name=\"wpforms[fields][56]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_56_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_56_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_56_2\" name=\"wpforms[fields][56]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_56_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_56_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_57-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_57\">In what year? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_57\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-17495-field_57-error\" required><\/div><div id=\"wpforms-17495-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_58\">Do you know which type? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-17495-field_58-error\" required><\/div><div id=\"wpforms-17495-field_59-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had special infectious diseases?                   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_59_1\" name=\"wpforms[fields][59]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_59_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_59_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_59_2\" name=\"wpforms[fields][59]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_59_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_59_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_60-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_60\">Which infectious diseases? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-17495-field_60-error\" required><\/div><div id=\"wpforms-17495-field_61-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"61\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"5\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-17495-field_62-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"62\"><div id=\"wpforms-17495-field_62\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_62-error\"><h4>Occupational and exposure risk<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_63-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">Do you have an occupational risk of blood-borne infectious diseases?  (currently daily patient contact) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_63_1\" name=\"wpforms[fields][63]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_63_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_63_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_63_2\" name=\"wpforms[fields][63]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_63_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_63_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_64-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_64\">If yes, namely? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-17495-field_64-error\" required><\/div><div id=\"wpforms-17495-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a needlestick injury? (for example, an injury with a needle smeared with blood from someone else, or another sharp with blood smeared object?)      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_65\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_65_1\" name=\"wpforms[fields][65]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_65_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_65_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_65_2\" name=\"wpforms[fields][65]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_65_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_65_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_66-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been administered blood products into the bloodstream?   (e.g.Blood transfusions)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_66\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_66_1\" name=\"wpforms[fields][66]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_66_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_66_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_66_2\" name=\"wpforms[fields][66]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_66_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_66_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_67-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_67\">When? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17495-field_67\" 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][67][date]\" aria-errormessage=\"wpforms-17495-field_67-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17495-field_68-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"68\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"6\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"6\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7  \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-17495-field_69-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"69\"><div id=\"wpforms-17495-field_69\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_69-error\"><h4>Risk behaviour<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_70-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"70\"><fieldset><legend class=\"wpforms-field-label\">Have you ever injected drugs into your veins (intravenously)?    <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_70\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_70_1\" name=\"wpforms[fields][70]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_70_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_70_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_70_2\" name=\"wpforms[fields][70]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_70_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_70_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_71-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"71\"><fieldset><legend class=\"wpforms-field-label\">Have you ever snorted drugs?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_71\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_71_1\" name=\"wpforms[fields][71]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_71_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_71_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_71_2\" name=\"wpforms[fields][71]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_71_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_71_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a tattoo?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_72\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_72_1\" name=\"wpforms[fields][72]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_72_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_72_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_72_2\" name=\"wpforms[fields][72]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_72_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_72_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_73-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_73\">If so, in which country was it placed and when? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_73\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][73]\" aria-errormessage=\"wpforms-17495-field_73-error\" required><\/div><div id=\"wpforms-17495-field_74-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"74\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a piercing\/earrings done?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_74\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_74_1\" name=\"wpforms[fields][74]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_74_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_74_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_74_2\" name=\"wpforms[fields][74]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_74_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_74_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_76-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_76\">If so, in which country was it set?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_76\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-17495-field_76-error\" required><\/div><div id=\"wpforms-17495-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"75\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had acupuncture?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_75_1\" name=\"wpforms[fields][75]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_75_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_75_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_75_2\" name=\"wpforms[fields][75]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_75_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_75_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_77-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_77\">If so in which country? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_77\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-17495-field_77-error\" required><\/div><div id=\"wpforms-17495-field_78-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had growth hormone treatment?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_78_1\" name=\"wpforms[fields][78]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_78_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_78_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_78_2\" name=\"wpforms[fields][78]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_78_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_78_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a tissue donation? (eg cornea)             <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_79\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_79_1\" name=\"wpforms[fields][79]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_79_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_79_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_79_2\" name=\"wpforms[fields][79]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_79_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_79_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a hair transplant?    <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_80\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_80_1\" name=\"wpforms[fields][80]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_80_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_80_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_80_2\" name=\"wpforms[fields][80]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_80_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_80_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_81-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had surgery or clinical treatment done abroad?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_81\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_81_1\" name=\"wpforms[fields][81]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_81_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_81_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_81_2\" name=\"wpforms[fields][81]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_81_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_81_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_82-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_82\">If so, where and when? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" aria-errormessage=\"wpforms-17495-field_82-error\" required><\/div><div id=\"wpforms-17495-field_83-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\">Have you gained a new sexual partner in the past year? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_83\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_83_1\" name=\"wpforms[fields][83]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_83_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_83_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_83_2\" name=\"wpforms[fields][83]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_83_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_83_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_84-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"84\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had sexual contact with an intravenous drug user? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_84\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_84_1\" name=\"wpforms[fields][84]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_84_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_84_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_84_2\" name=\"wpforms[fields][84]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_84_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_84_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_85-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"85\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had sexual contact with someone who was subsequently found to be infected with HIV\/HTLV\/Hepatitis\/Lues? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_85\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_85_1\" name=\"wpforms[fields][85]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_85_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_85_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_85_2\" name=\"wpforms[fields][85]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_85_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_85_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_86-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"86\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">With what? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_86_1\" name=\"wpforms[fields][86]\" value=\"HIV\" aria-errormessage=\"wpforms-17495-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_86_1\">HIV<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_86_2\" name=\"wpforms[fields][86]\" value=\"Lues\" aria-errormessage=\"wpforms-17495-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_86_2\">Lues<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_86_3\" name=\"wpforms[fields][86]\" value=\"Hepatitis\" aria-errormessage=\"wpforms-17495-field_86_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_86_3\">Hepatitis<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_86_4\" name=\"wpforms[fields][86]\" value=\"HTLV\" aria-errormessage=\"wpforms-17495-field_86_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_86_4\">HTLV<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_86_5\" name=\"wpforms[fields][86]\" value=\"Other:\" aria-errormessage=\"wpforms-17495-field_86_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_86_5\">Other:<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_87\">Other: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_87\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][87]\" aria-errormessage=\"wpforms-17495-field_87-error\" required><\/div><div id=\"wpforms-17495-field_88-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Have you ever had a sexually transmitted disease (STD)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_88\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_88_1\" name=\"wpforms[fields][88]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_88_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_88_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_88_2\" name=\"wpforms[fields][88]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_88_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_88_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_89-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_89\">Which one? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_89\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-17495-field_89-error\" required><\/div><div id=\"wpforms-17495-field_90-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"90\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"7\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"7\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-8  \" data-page=\"8\" style=\"display:none;\"><div id=\"wpforms-17495-field_91-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"91\"><div id=\"wpforms-17495-field_91\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_91-error\"><h4>Vaccinations<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_92-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis A? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_92\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_92_1\" name=\"wpforms[fields][92]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_92_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_92_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_92_2\" name=\"wpforms[fields][92]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_92_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_92_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_94-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Was the titer sufficient? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_94\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_94_1\" name=\"wpforms[fields][94]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_94_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_94_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_94_2\" name=\"wpforms[fields][94]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_94_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_94_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_95-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Have you been vaccinated (i.e. not a single immunoglobulin injection) for Hepatitis B? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_95\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_95_1\" name=\"wpforms[fields][95]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_95_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_95_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_95_2\" name=\"wpforms[fields][95]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_95_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_95_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_96-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Was the titer sufficient? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_96\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_96_1\" name=\"wpforms[fields][96]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_96_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_96_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_96_2\" name=\"wpforms[fields][96]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_96_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_96_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_97-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Do hereditary diseases run in the family? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_97\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_97_1\" name=\"wpforms[fields][97]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_97_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_97_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_97_2\" name=\"wpforms[fields][97]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_97_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_97_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_98-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"98\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_98\">Which ones? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_98\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][98]\" aria-errormessage=\"wpforms-17495-field_98-error\" required><\/div><div id=\"wpforms-17495-field_99-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"99\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"8\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"8\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-9  \" data-page=\"9\" style=\"display:none;\"><div id=\"wpforms-17495-field_100-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">What type of stool do you have? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_100\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_1\" name=\"wpforms[fields][100]\" value=\"Type 1\" aria-errormessage=\"wpforms-17495-field_100_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_1\">Type 1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_2\" name=\"wpforms[fields][100]\" value=\"Type 2\" aria-errormessage=\"wpforms-17495-field_100_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_2\">Type 2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_3\" name=\"wpforms[fields][100]\" value=\"Type 3\" aria-errormessage=\"wpforms-17495-field_100_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_3\">Type 3<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_4\" name=\"wpforms[fields][100]\" value=\"Type 4\" aria-errormessage=\"wpforms-17495-field_100_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_4\">Type 4<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_5\" name=\"wpforms[fields][100]\" value=\"Type 5\" aria-errormessage=\"wpforms-17495-field_100_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_5\">Type 5<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_6\" name=\"wpforms[fields][100]\" value=\"Type 6\" aria-errormessage=\"wpforms-17495-field_100_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_6\">Type 6<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_100_7\" name=\"wpforms[fields][100]\" value=\"Type 7\" aria-errormessage=\"wpforms-17495-field_100_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_100_7\">Type 7<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_101-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"101\"><div id=\"wpforms-17495-field_101\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_101-error\"><h4>Gut Health<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_102-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"102\"><div id=\"wpforms-17495-field_102\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_102-error\"><p><img decoding=\"async\" height=\"568\" width=\"440\" alt=\"\" src=\"https:\/\/gezonde-darmflora.nl\/wp-content\/uploads\/2024\/04\/Picture-1.jpg\" class=\"alignnone wp-image-17408 size-full\" srcset=\"https:\/\/gezonde-darmflora.nl\/wp-content\/uploads\/2024\/04\/Picture-1.jpg 440w, https:\/\/gezonde-darmflora.nl\/wp-content\/uploads\/2024\/04\/Picture-1-232x300.jpg 232w\" sizes=\"(max-width: 440px) 100vw, 440px\" \/><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_103-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_103\">How many times a day do you have bowel movements on average? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_103\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][103]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_103-error\" required><\/div><div id=\"wpforms-17495-field_105-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"105\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you have a regular stool pattern? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_105\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_105_1\" name=\"wpforms[fields][105]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_105_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_105_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_105_2\" name=\"wpforms[fields][105]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_105_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_105_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_106-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"106\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you suffer from excessive daily flatulence (flatulence)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_106\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_106_1\" name=\"wpforms[fields][106]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_106_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_106_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_106_2\" name=\"wpforms[fields][106]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_106_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_106_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_107-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_107\">If so, how often is this on average in a day? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_107\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][107]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_107-error\" required><\/div><div id=\"wpforms-17495-field_108-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"108\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Have you ever been treated for an intestinal infection? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_108\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_108_1\" name=\"wpforms[fields][108]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_108_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_108_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_108_2\" name=\"wpforms[fields][108]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_108_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_108_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_109-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_109\">When was the last time? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17495-field_109\" 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][109][date]\" aria-errormessage=\"wpforms-17495-field_109-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17495-field_110-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"110\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you have a chronic bowel disease?  (e.g. Crohn&#039;s disease\/Ulcerative colitis\/Celiac disease)     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_110\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_110_1\" name=\"wpforms[fields][110]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_110_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_110_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_110_2\" name=\"wpforms[fields][110]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_110_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_110_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_111-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"111\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_111\">If so, which one? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_111\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-17495-field_111-error\" required><\/div><div id=\"wpforms-17495-field_112-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"112\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you ever drink products especially for your bowel movements?  (activities\/yakult\/actimel etc?)       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_112\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_112_1\" name=\"wpforms[fields][112]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_112_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_112_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_112_2\" name=\"wpforms[fields][112]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_112_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_112_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_113-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"113\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_113\">How many times? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_113\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][113]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_113-error\" aria-describedby=\"wpforms-17495-field_113-description\" required><div id=\"wpforms-17495-field_113-description\" class=\"wpforms-field-description\">... times per day<\/div><\/div><div id=\"wpforms-17495-field_114-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"114\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you ever (more than once a month) suffer from difficult bowel movements (constipation) so that you have to strain for a long time to get the stool out?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_114\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_114_1\" name=\"wpforms[fields][114]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_114_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_114_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_114_2\" name=\"wpforms[fields][114]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_114_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_114_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_115-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"115\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_115\">If so, how often is this on average per month? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_115\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][115]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_115-error\" aria-describedby=\"wpforms-17495-field_115-description\" required><div id=\"wpforms-17495-field_115-description\" class=\"wpforms-field-description\">... times<\/div><\/div><div id=\"wpforms-17495-field_116-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"116\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you suffer from hemorrhoids?                  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_116\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_116_1\" name=\"wpforms[fields][116]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_116_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_116_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_116_2\" name=\"wpforms[fields][116]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_116_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_116_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_117-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"117\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you often have intestinal cramps?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_117\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_117_1\" name=\"wpforms[fields][117]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_117_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_117_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_117_2\" name=\"wpforms[fields][117]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_117_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_117_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_118-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"118\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you ever take medication to facilitate\/slow down bowel movements?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_118\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_118_1\" name=\"wpforms[fields][118]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_118_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_118_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_118_2\" name=\"wpforms[fields][118]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_118_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_118_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_119-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"119\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you ever take certain foods (plums\/fibres) to help with bowel movements? to ease?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_119\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_119_1\" name=\"wpforms[fields][119]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_119_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_119_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_119_2\" name=\"wpforms[fields][119]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_119_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_119_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_120-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"120\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do bowel disorders run in your family?               <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_120\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_120_1\" name=\"wpforms[fields][120]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_120_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_120_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_120_2\" name=\"wpforms[fields][120]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_120_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_120_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_122-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"122\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_122\">If so, which ones and with whom? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17495-field_122\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][122]\" aria-errormessage=\"wpforms-17495-field_122-error\" required><\/textarea><\/div><div id=\"wpforms-17495-field_123-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"123\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Does colon cancer or polyps run in your family?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_123\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_123_1\" name=\"wpforms[fields][123]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_123_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_123_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_123_2\" name=\"wpforms[fields][123]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_123_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_123_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_124-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"124\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_124\">With whom? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_124\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][124]\" aria-errormessage=\"wpforms-17495-field_124-error\" required><\/div><div id=\"wpforms-17495-field_125-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"125\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_125\">At what age? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17495-field_125\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][125]\" step=\"any\" aria-errormessage=\"wpforms-17495-field_125-error\" required><\/div><div id=\"wpforms-17495-field_126-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"126\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"9\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"9\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-10  \" data-page=\"10\" style=\"display:none;\"><div id=\"wpforms-17495-field_127-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"127\"><div id=\"wpforms-17495-field_127\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_127-error\"><h4>Antibiotic use<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_128-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"128\"><fieldset><legend class=\"wpforms-field-label\">Have you ever taken antibiotics? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_128\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_128_1\" name=\"wpforms[fields][128]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_128_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_128_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_128_2\" name=\"wpforms[fields][128]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_128_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_128_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_129-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"129\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Have you taken antibiotics in the past three months? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_129\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_129_1\" name=\"wpforms[fields][129]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_129_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_129_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_129_2\" name=\"wpforms[fields][129]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_129_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_129_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_131-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"131\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_131\">Can you remember which antibiotic? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_131\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][131]\" aria-errormessage=\"wpforms-17495-field_131-error\" required><\/div><div id=\"wpforms-17495-field_132-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"132\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_132\">When and for how many days? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_132\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-17495-field_132-error\" required><\/div><div id=\"wpforms-17495-field_133-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"133\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Have you used antibiotics in the past year? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_133\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_133_1\" name=\"wpforms[fields][133]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_133_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_133_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_133_2\" name=\"wpforms[fields][133]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_133_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_133_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_134-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"134\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_134\">Can you remember which antibiotic? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_134\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][134]\" aria-errormessage=\"wpforms-17495-field_134-error\" required><\/div><div id=\"wpforms-17495-field_135-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"135\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_135\">When and for how many days? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17495-field_135\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][135]\" aria-errormessage=\"wpforms-17495-field_135-error\" required><\/div><div id=\"wpforms-17495-field_136-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"136\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"10\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"10\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-11  \" data-page=\"11\" style=\"display:none;\"><div id=\"wpforms-17495-field_137-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"137\"><div id=\"wpforms-17495-field_137\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_137-error\"><h4>Additional Health Issues<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_138-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"138\"><fieldset><legend class=\"wpforms-field-label\">Have you ever experienced rectal bleeding? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_138\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_138_1\" name=\"wpforms[fields][138]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_138_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_138_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_138_2\" name=\"wpforms[fields][138]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_138_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_138_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_140-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"140\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Has additional research been carried out? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_140\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_140_1\" name=\"wpforms[fields][140]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_140_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_140_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_140_2\" name=\"wpforms[fields][140]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_140_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_140_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_141-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"141\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_141\">What were the results? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17495-field_141\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][141]\" aria-errormessage=\"wpforms-17495-field_141-error\" required><\/textarea><\/div><div id=\"wpforms-17495-field_142-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"142\"><fieldset><legend class=\"wpforms-field-label\">Have you had a fever in the past two weeks? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_142\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_142_1\" name=\"wpforms[fields][142]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_142_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_142_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_142_2\" name=\"wpforms[fields][142]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_142_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_142_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_143-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"143\"><fieldset><legend class=\"wpforms-field-label\">Have you had diarrhoea in the last 3 months? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_143\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_143_1\" name=\"wpforms[fields][143]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_143_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_143_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_143_2\" name=\"wpforms[fields][143]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_143_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_143_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17495-field_144-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"144\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_144\">When did this start and how long did it last? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17495-field_144\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-17495-field_144-error\" required><\/textarea><\/div><div id=\"wpforms-17495-field_145-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"145\"><fieldset><legend class=\"wpforms-field-label\">Do you suffer from allergies? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17495-field_145\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_145_1\" name=\"wpforms[fields][145]\" value=\"Yes\" aria-errormessage=\"wpforms-17495-field_145_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_145_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17495-field_145_2\" name=\"wpforms[fields][145]\" value=\"No\" aria-errormessage=\"wpforms-17495-field_145_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17495-field_145_2\">No<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-17495-field_3-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"3\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-17495-field_3\" >donation?  antibiotic?<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-17495-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-17495-field_146-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"146\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"11\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"11\" data-formid=\"17495\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-12 last \" data-page=\"12\" style=\"display:none;\"><div id=\"wpforms-17495-field_147-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"147\"><div id=\"wpforms-17495-field_147\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17495-field_147-error\"><h4>Additions<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17495-field_148-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"148\"><label class=\"wpforms-field-label\" for=\"wpforms-17495-field_148\">Are there any other things you would like to say or explain?<\/label><textarea id=\"wpforms-17495-field_148\" class=\"wpforms-field-medium\" name=\"wpforms[fields][148]\" aria-errormessage=\"wpforms-17495-field_148-error\" ><\/textarea><\/div><div id=\"wpforms-17495-field_9-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"9\"><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-17495-field_3-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-17495-field_3-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-17495-field_3-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"17495\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/gezonde-darmflora.nl\/en\/wp-json\/wp\/v2\/pages\/17493\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-17495\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Send\" aria-live=\"assertive\" value=\"wpforms-submit\">Send<\/button><img decoding=\"async\" src=\"https:\/\/gezonde-darmflora.nl\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row full_width=&#8221;stretch_row_content_no_spaces&#8221;][vc_column][\/vc_column][\/vc_row][vc_row][vc_column][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-17493","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.1.1 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Donor questionnaire &#8211; Gezonde Darmflora<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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