{"id":17741,"date":"2025-04-09T16:02:21","date_gmt":"2025-04-09T14:02:21","guid":{"rendered":"https:\/\/gezonde-darmflora.nl\/devenir-donateur\/"},"modified":"2025-05-08T17:10:30","modified_gmt":"2025-05-08T15:10:30","slug":"devenir-donateur","status":"publish","type":"page","link":"https:\/\/gezonde-darmflora.nl\/fr\/devenir-donateur\/","title":{"rendered":"Devenir donateur"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=\u00a0\u00bbstretch_row_content_no_spaces\u00a0\u00bb][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>Devenir donateur<\/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-17747\">\n\t\t\t\t#wpforms-17747 {\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-17747\"><form id=\"wpforms-form-17747\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"17747\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/17741\" data-token=\"dd3eb23f9dabb50ec82676681ab2d4f6\" data-token-time=\"1775737921\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/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\">\u00c9tape <span class=\"wpforms-page-indicator-steps-current\">1<\/span> sur 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-17747-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"1\"><div id=\"wpforms-17747-field_1\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_1-error\"><h4>Donn\u00e9es personnelles<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_152-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"152\"><fieldset><legend class=\"wpforms-field-label\">Nom <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-17747-field_152\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][152][first]\" aria-errormessage=\"wpforms-17747-field_152-error\" required><label for=\"wpforms-17747-field_152\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-17747-field_152-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][152][last]\" aria-errormessage=\"wpforms-17747-field_152-last-error\" required><label for=\"wpforms-17747-field_152-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-17747-field_2-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_2\">Date de naissance <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17747-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-17747-field_2-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17747-field_153-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"153\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_153\">Courrier \u00e9lectronique <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-17747-field_153\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][153]\" spellcheck=\"false\" aria-errormessage=\"wpforms-17747-field_153-error\" required><\/div><div id=\"wpforms-17747-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_4\">T\u00e9l\u00e9phone portable <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-17747-field_4-error\" required><\/div><div id=\"wpforms-17747-field_154-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"154\"><fieldset><legend class=\"wpforms-field-label\">Adresse<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-17747-field_154\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][154][address1]\" aria-errormessage=\"wpforms-17747-field_154-error\" ><label for=\"wpforms-17747-field_154\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/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-17747-field_154-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][154][city]\" aria-errormessage=\"wpforms-17747-field_154-city-error\" ><label for=\"wpforms-17747-field_154-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-17747-field_154-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][154][state]\" aria-errormessage=\"wpforms-17747-field_154-state-error\" ><label for=\"wpforms-17747-field_154-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/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-17747-field_154-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][154][postal]\" aria-errormessage=\"wpforms-17747-field_154-postal-error\" ><label for=\"wpforms-17747-field_154-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-17747-field_154-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][154][country]\" aria-errormessage=\"wpforms-17747-field_154-country-error\" ><option class=\"placeholder\" value=\"\" selected disabled>--- S\u00e9lectionner\u00a0: country ---<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"ZA\" >Afrique du Sud<\/option><option value=\"AL\" >Albanie<\/option><option value=\"DZ\" >Alg\u00e9rie<\/option><option value=\"DE\" >Allemagne<\/option><option value=\"AD\" >Andorre<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctique<\/option><option value=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"SA\" >Arabie Saoudite<\/option><option value=\"AR\" >Argentine<\/option><option value=\"AM\" >Arm\u00e9nie<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australie<\/option><option value=\"AT\" >Autriche<\/option><option value=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahre\u00efn<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbade<\/option><option value=\"BE\" >Belgique<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BM\" >Bermudes<\/option><option value=\"BT\" >Bhoutan<\/option><option value=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"BO\" >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BR\" >Br\u00e9sil<\/option><option value=\"BG\" >Bulgarie<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"BJ\" >B\u00e9nin<\/option><option value=\"KH\" >Cambodge<\/option><option value=\"CM\" >Cameroun<\/option><option value=\"CA\" >Canada<\/option><option value=\"CV\" >Cap-Vert<\/option><option value=\"CL\" >Chili<\/option><option value=\"CN\" >Chine<\/option><option value=\"CY\" >Chypre<\/option><option value=\"CO\" >Colombie<\/option><option value=\"KM\" >Comores<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"KR\" >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"KP\" >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatie<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"DK\" >Danemark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominique<\/option><option value=\"ES\" >Espagne<\/option><option value=\"EE\" >Estonie<\/option><option value=\"SZ\" >Eswatini (Royaume de)<\/option><option value=\"FJ\" >Fidji<\/option><option value=\"FI\" >Finlande<\/option><option value=\"FR\" >France<\/option><option value=\"RU\" >F\u00e9d\u00e9ration Russe<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambie<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GD\" >Grenade<\/option><option value=\"GL\" >Groenland<\/option><option value=\"GR\" >Gr\u00e8ce<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernesey<\/option><option value=\"GN\" >Guin\u00e9e<\/option><option value=\"GQ\" >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"GF\" >Guyane<\/option><option value=\"GY\" >Guyane<\/option><option value=\"GE\" >G\u00e9orgie<\/option><option value=\"GS\" >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"HT\" >Ha\u00efti<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hongrie<\/option><option value=\"IN\" >Inde<\/option><option value=\"ID\" >Indon\u00e9sie<\/option><option value=\"IQ\" >Irak<\/option><option value=\"IR\" >Iran (R\u00e9publique islamique d\u2019)<\/option><option value=\"IE\" >Irlande (R\u00e9publique d\u2019)<\/option><option value=\"IS\" >Islande<\/option><option value=\"IL\" >Isra\u00ebl<\/option><option value=\"IT\" >Italie<\/option><option value=\"JM\" >Jama\u00efque<\/option><option value=\"JP\" >Japon<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordanie<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KG\" >Kirghizistan<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kowe\u00eft<\/option><option value=\"RE\" >La R\u00e9union<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LV\" >Lettonie<\/option><option value=\"LB\" >Liban<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libye<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lituanie<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MY\" >Malaisie<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malte<\/option><option value=\"MA\" >Maroc<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritanie<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexique<\/option><option value=\"FM\" >Micron\u00e9sie (\u00c9tats f\u00e9d\u00e9r\u00e9s de)<\/option><option value=\"MD\" >Moldova (R\u00e9publique de)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolie<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibie<\/option><option value=\"NR\" >Nauru<\/option><option value=\"BN\" >Negara Brunei Darussalam<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nig\u00e9ria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NO\" >Norv\u00e8ge<\/option><option value=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"NP\" >N\u00e9pal<\/option><option value=\"OM\" >Oman<\/option><option value=\"UG\" >Ouganda<\/option><option value=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (\u00c9tat de)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"NL\" >Pays-Bas<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PL\" >Pologne<\/option><option value=\"PF\" >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"PR\" >Porto Rico<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PE\" >P\u00e9rou<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Roumanie<\/option><option value=\"GB\" >Royaume-Uni de Grande-Bretagne et d\u2019Irlande du Nord<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"SY\" >R\u00e9publique arabe syrienne<\/option><option value=\"CF\" >R\u00e9publique centrafricaine<\/option><option value=\"DO\" >R\u00e9publique dominicaine<\/option><option value=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"CZ\" >R\u00e9publique tch\u00e8que<\/option><option value=\"EH\" >Sahara occidental<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"KN\" >Saint-Christophe-et-Nevis<\/option><option value=\"SM\" >Saint-Marin<\/option><option value=\"MF\" >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"VC\" >Saint-Vincent-et-les Grenadines<\/option><option value=\"SH\" >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"LC\" >Sainte-Lucie<\/option><option value=\"SV\" >Salvador<\/option><option value=\"WS\" >Samoa<\/option><option value=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"ST\" >Sao Tom\u00e9 et Principe<\/option><option value=\"RS\" >Serbie<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapour<\/option><option value=\"SX\" >Sint Maarten (partie hollandaise)<\/option><option value=\"SK\" >Slovaquie<\/option><option value=\"SI\" >Slov\u00e9nie<\/option><option value=\"SO\" >Somalie<\/option><option value=\"SD\" >Soudan<\/option><option value=\"SS\" >Soudan du Sud<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"CH\" >Suisse<\/option><option value=\"SR\" >Surinam<\/option><option value=\"SE\" >Su\u00e8de<\/option><option value=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"TJ\" >Tadjikistan<\/option><option value=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"TZ\" >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"TD\" >Tchad<\/option><option value=\"TF\" >Terres Australes Fran\u00e7aises<\/option><option value=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"TH\" >Tha\u00eflande<\/option><option value=\"TL\" >Timor oriental<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"TN\" >Tunisie<\/option><option value=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"TR\" >Turquie<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VE\" >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"WF\" >Wallis et Futuna<\/option><option value=\"YE\" >Y\u00e9men<\/option><option value=\"ZM\" >Zambie<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"EG\" >\u00c9gypte<\/option><option value=\"AE\" >\u00c9mirats arabes unis<\/option><option value=\"EC\" >\u00c9quateur<\/option><option value=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"VA\" >\u00c9tat de la cit\u00e9 du Vatican<\/option><option value=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique<\/option><option value=\"ET\" >\u00c9thiopie<\/option><option value=\"BV\" >\u00cele Bouvet<\/option><option value=\"CX\" >\u00cele Christmas<\/option><option value=\"MU\" >\u00cele Maurice<\/option><option value=\"NF\" >\u00cele Norfolk<\/option><option value=\"IM\" >\u00cele de Man<\/option><option value=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"CC\" >\u00celes Cocos (Keeling)<\/option><option value=\"CK\" >\u00celes Cook<\/option><option value=\"FK\" >\u00celes Falkland (Malvinas)<\/option><option value=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"HM\" >\u00celes Heard et McDonald<\/option><option value=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"MH\" >\u00celes Marshall<\/option><option value=\"PN\" >\u00celes Pitcairn<\/option><option value=\"SB\" >\u00celes Salomon<\/option><option value=\"TC\" >\u00celes Turques et Ca\u00efques<\/option><option value=\"VI\" >\u00celes Vierges (Am\u00e9ricaines)<\/option><option value=\"VG\" >\u00celes Vierges (Britanniques)<\/option><option value=\"SJ\" >\u00celes de Svalbard et Jan Mayen<\/option><option value=\"UM\" >\u00celes mineures am\u00e9ricaines<\/option><option value=\"AX\" >\u00celes \u00c5land<\/option><\/select><label for=\"wpforms-17747-field_154-country\" class=\"wpforms-field-sublabel after\">Pays<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-17747-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">Genre <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_6_1\" name=\"wpforms[fields][6]\" value=\"Homme\" aria-errormessage=\"wpforms-17747-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_6_1\">Homme<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_6_2\" name=\"wpforms[fields][6]\" value=\"Femme\" aria-errormessage=\"wpforms-17747-field_6_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_6_2\">Femme<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-17747-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><\/div><div id=\"wpforms-17747-field_10-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"10\"><div id=\"wpforms-17747-field_10\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_10-error\"><h4>Donn\u00e9es corporelles et sant\u00e9 g\u00e9n\u00e9rale<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_11\">Quel est votre poids ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-17747-field_11-error\" aria-describedby=\"wpforms-17747-field_11-description\" required><div id=\"wpforms-17747-field_11-description\" class=\"wpforms-field-description\">En kilo<\/div><\/div><div id=\"wpforms-17747-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_12\">Quelle est votre taille ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" aria-errormessage=\"wpforms-17747-field_12-error\" aria-describedby=\"wpforms-17747-field_12-description\" required><div id=\"wpforms-17747-field_12-description\" class=\"wpforms-field-description\">En CM<\/div><\/div><div id=\"wpforms-17747-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_13\">Quel est votre IMC ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-17747-field_13-error\" aria-describedby=\"wpforms-17747-field_13-description\" required><div id=\"wpforms-17747-field_13-description\" class=\"wpforms-field-description\">En cm\/kg2<\/div><\/div><div id=\"wpforms-17747-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_14\">Quelle est votre profession\/\u00e9tude ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-17747-field_14-error\" required><\/div><div id=\"wpforms-17747-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_15\">Quel est votre niveau d&#039;\u00e9ducation ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-17747-field_15-error\" required><\/div><div id=\"wpforms-17747-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_16\">Quelle est la composition de votre famille ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-17747-field_16-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-17747-field_18-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"18\"><div id=\"wpforms-17747-field_18\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_18-error\"><h4>Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous n\u00e9e par voie naturelle ou par c\u00e9sarienne ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_19_1\" name=\"wpforms[fields][19]\" value=\"Naturellement\" aria-errormessage=\"wpforms-17747-field_19_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_19_1\">Naturellement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_19_2\" name=\"wpforms[fields][19]\" value=\"C\u00e9sarienne\" aria-errormessage=\"wpforms-17747-field_19_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_19_2\">C\u00e9sarienne<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_20\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_20_1\" name=\"wpforms[fields][20]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_20_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_20_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_20_2\" name=\"wpforms[fields][20]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_20_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_20_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 rejet\u00e9 lors d&#039;un examen (en tant que donneur ou autre) ?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_22\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_22_1\" name=\"wpforms[fields][22]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_22_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_22_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_22_2\" name=\"wpforms[fields][22]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_22_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_22_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_23\"> Pourquoi <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17747-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-17747-field_23-error\" required><\/textarea><\/div><div id=\"wpforms-17747-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 donn\u00e9 du sang ?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_24_1\" name=\"wpforms[fields][24]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_24_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_24_2\" name=\"wpforms[fields][24]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_24_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_24_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_27\">Si oui, \u00e0 quand remonte la derni\u00e8re fois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17747-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-17747-field_27-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17747-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"28\"><fieldset><legend class=\"wpforms-field-label\">Si oui, quand \u00e9tait-ce la derni\u00e8re foisAvez-vous d\u00e9j\u00e0 consult\u00e9 un sp\u00e9cialiste (m\u00e9decin \u00e0 l&#039;h\u00f4pital) ?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_28\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_28_1\" name=\"wpforms[fields][28]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_28_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_28_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_28_2\" name=\"wpforms[fields][28]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_28_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_28_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_29\">Quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17747-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-17747-field_29-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17747-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous vaccin\u00e9 contre le covid-19 ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_30_1\" name=\"wpforms[fields][30]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_30_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_30_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_30_2\" name=\"wpforms[fields][30]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_30_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_30_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_31\">Combien de fois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_31-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_32\">Quel fabricant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-17747-field_32-error\" required><\/div><div id=\"wpforms-17747-field_33-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Prenez-vous des m\u00e9dicaments ?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_33\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_33_1\" name=\"wpforms[fields][33]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_33_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_33_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_33_2\" name=\"wpforms[fields][33]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_33_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_33_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_34\">Si oui, quels m\u00e9dicaments avez-vous re\u00e7us ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_34\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][34]\" aria-errormessage=\"wpforms-17747-field_34-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_35\">En quelle ann\u00e9e ce traitement a-t-il commenc\u00e9 ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_35\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][35]\" aria-errormessage=\"wpforms-17747-field_35-error\" required><\/div><div id=\"wpforms-17747-field_36-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"36\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous \u00e9t\u00e9 d\u00e9prim\u00e9 dans le pass\u00e9 ?        <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_36\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_36_1\" name=\"wpforms[fields][36]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_36_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_36_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_36_2\" name=\"wpforms[fields][36]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_36_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_36_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_37\">Quand cela a-t-il commenc\u00e9 et depuis combien de temps ?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_37\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-17747-field_37-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_38\">Avez-vous pris des m\u00e9dicaments pour cela ?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_38\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-17747-field_38-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-17747-field_40-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"40\"><div id=\"wpforms-17747-field_40\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_40-error\"><h4>Troubles chroniques et h\u00e9r\u00e9dit\u00e9<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"41\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous \u00e9t\u00e9 trait\u00e9 pour l&#039;autisme ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_41\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_41_1\" name=\"wpforms[fields][41]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_41_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_41_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_41_2\" name=\"wpforms[fields][41]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_41_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_41_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_42-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"42\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 subi un test de d\u00e9pistage du diab\u00e8te ?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_42\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_42_1\" name=\"wpforms[fields][42]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_42_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_42_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_42_2\" name=\"wpforms[fields][42]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_42_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_42_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-17747-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-17747-field_3\" >avec  oui,<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-17747-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-17747-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-17747-field_43\">Quel a \u00e9t\u00e9 le r\u00e9sultat ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-17747-field_43-error\" required><\/div><div id=\"wpforms-17747-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Le diab\u00e8te est-il un probl\u00e8me familial ?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_44_1\" name=\"wpforms[fields][44]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_44_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_44_2\" name=\"wpforms[fields][44]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_44_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"45\"><fieldset><legend class=\"wpforms-field-label\">Existe-t-il des ant\u00e9c\u00e9dents familiaux de schizophr\u00e9nie, de troubles bipolaires ou de troubles anxieux ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_45\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_45_1\" name=\"wpforms[fields][45]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_45_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_45_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_45_2\" name=\"wpforms[fields][45]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_45_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_45_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_46-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">La maladie de Creuzfeldt-Jakob est-elle pr\u00e9sente dans votre famille ?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_46\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_46_1\" name=\"wpforms[fields][46]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_46_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_46_2\" name=\"wpforms[fields][46]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_46_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><fieldset><legend class=\"wpforms-field-label\">La d\u00e9mence est-elle pr\u00e9sente dans votre famille avant l&#039;\u00e2ge de 60 ans ?                <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_47\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_47_1\" name=\"wpforms[fields][47]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_47_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_47_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_47_2\" name=\"wpforms[fields][47]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_47_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_47_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-17747-field_49-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"49\"><div id=\"wpforms-17747-field_49\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_49-error\"><h4>Environnement et zones \u00e0 risque<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_50-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"50\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous des animaux domestiques ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_50\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_50_1\" name=\"wpforms[fields][50]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_50_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_50_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_50_2\" name=\"wpforms[fields][50]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_50_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_50_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_51-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous n\u00e9 dans un pays non europ\u00e9en ou avez-vous v\u00e9cu plus longtemps dans un pays non europ\u00e9en pendant 5 ans ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_51\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_51_1\" name=\"wpforms[fields][51]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_51_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_51_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_51_2\" name=\"wpforms[fields][51]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_51_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_51_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_52\">O\u00f9 et quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_52\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-17747-field_52-error\" required><\/div><div id=\"wpforms-17747-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous s\u00e9journ\u00e9 au Royaume-Uni pendant plus de 6 mois entre 1980 et 1996 r\u00e9unis ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_53\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_53_1\" name=\"wpforms[fields][53]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_53_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_53_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_53_2\" name=\"wpforms[fields][53]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_53_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_53_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"54\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous all\u00e9 sous les tropiques au cours des deux derni\u00e8res ann\u00e9es ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_54\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_54_1\" name=\"wpforms[fields][54]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_54_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_54_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_54_2\" name=\"wpforms[fields][54]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_54_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_54_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_55\">O\u00f9 et en quelle ann\u00e9e ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-17747-field_55-error\" required><\/div><div id=\"wpforms-17747-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"56\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu le paludisme ?         <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_56\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_56_1\" name=\"wpforms[fields][56]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_56_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_56_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_56_2\" name=\"wpforms[fields][56]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_56_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_56_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_57\">En quelle ann\u00e9e ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_57\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][57]\" aria-errormessage=\"wpforms-17747-field_57-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_58\">Savez-vous de quel type il s&#039;agit ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" aria-errormessage=\"wpforms-17747-field_58-error\" required><\/div><div id=\"wpforms-17747-field_59-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"59\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu des maladies infectieuses particuli\u00e8res ?                   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_59_1\" name=\"wpforms[fields][59]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_59_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_59_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_59_2\" name=\"wpforms[fields][59]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_59_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_59_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_60\">Quelles sont les maladies infectieuses ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" aria-errormessage=\"wpforms-17747-field_60-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"5\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-17747-field_62-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"62\"><div id=\"wpforms-17747-field_62\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_62-error\"><h4>Risque professionnel et risque d'exposition<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_63-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"63\"><fieldset><legend class=\"wpforms-field-label\">\u00cates-vous expos\u00e9 \u00e0 un risque professionnel de maladies infectieuses transmises par le sang ?  (actuellement en contact quotidien avec des patients) <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_63\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_63_1\" name=\"wpforms[fields][63]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_63_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_63_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_63_2\" name=\"wpforms[fields][63]\" value=\"No\" aria-errormessage=\"wpforms-17747-field_63_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_63_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_64\">Si oui, \u00e0 savoir ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" aria-errormessage=\"wpforms-17747-field_64-error\" required><\/div><div id=\"wpforms-17747-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"65\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 victime d&#039;une piq\u00fbre d&#039;aiguille ? (par exemple, une blessure avec une aiguille enduite de sang de quelqu&#039;un d&#039;autre, ou un autre objet pointu enduit de sang) ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_65\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_65_1\" name=\"wpforms[fields][65]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_65_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_65_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_65_2\" name=\"wpforms[fields][65]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_65_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_65_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_66-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 re\u00e7u des produits sanguins dans la circulation sanguine ?   (par exemple, des transfusions sanguines) ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_66\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_66_1\" name=\"wpforms[fields][66]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_66_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_66_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_66_2\" name=\"wpforms[fields][66]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_66_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_66_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_67\">Quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17747-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-17747-field_67-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"6\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7  \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-17747-field_69-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"69\"><div id=\"wpforms-17747-field_69\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_69-error\"><h4>Risk behaviour<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_70-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"70\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 inject\u00e9 des drogues dans vos veines (par voie intraveineuse) ?    <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_70\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_70_1\" name=\"wpforms[fields][70]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_70_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_70_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_70_2\" name=\"wpforms[fields][70]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_70_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_70_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_71-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"71\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 sniff\u00e9 de la drogue ?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_71\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_71_1\" name=\"wpforms[fields][71]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_71_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_71_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_71_2\" name=\"wpforms[fields][71]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_71_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_71_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu un tatouage ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_72\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_72_1\" name=\"wpforms[fields][72]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_72_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_72_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_72_2\" name=\"wpforms[fields][72]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_72_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_72_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_73\">Si oui, dans quel pays a-t-il \u00e9t\u00e9 plac\u00e9 et quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_73\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][73]\" aria-errormessage=\"wpforms-17747-field_73-error\" required><\/div><div id=\"wpforms-17747-field_74-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"74\"><fieldset><legend class=\"wpforms-field-label\">Si oui, dans quel pays a-t-il \u00e9t\u00e9 plac\u00e9 et quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_74\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_74_1\" name=\"wpforms[fields][74]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_74_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_74_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_74_2\" name=\"wpforms[fields][74]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_74_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_74_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_76\">Si oui, dans quel pays s&#039;est-il d\u00e9roul\u00e9 ?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_76\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-17747-field_76-error\" required><\/div><div id=\"wpforms-17747-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"75\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu recours \u00e0 l&#039;acupuncture ?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_75_1\" name=\"wpforms[fields][75]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_75_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_75_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_75_2\" name=\"wpforms[fields][75]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_75_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_75_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_77\">Si oui, dans quel pays ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_77\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][77]\" aria-errormessage=\"wpforms-17747-field_77-error\" required><\/div><div id=\"wpforms-17747-field_78-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 re\u00e7u un traitement \u00e0 l&#039;hormone de croissance ?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_78_1\" name=\"wpforms[fields][78]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_78_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_78_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_78_2\" name=\"wpforms[fields][78]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_78_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_78_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_79-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 b\u00e9n\u00e9fici\u00e9 d&#039;un don de tissus ? (par exemple la corn\u00e9e)             <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_79\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_79_1\" name=\"wpforms[fields][79]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_79_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_79_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_79_2\" name=\"wpforms[fields][79]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_79_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_79_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"80\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 subi une greffe de cheveux ?    <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_80\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_80_1\" name=\"wpforms[fields][80]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_80_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_80_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_80_2\" name=\"wpforms[fields][80]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_80_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_80_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_81-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"81\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 subi une intervention chirurgicale ou un traitement clinique \u00e0 l&#039;\u00e9tranger ?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_81\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_81_1\" name=\"wpforms[fields][81]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_81_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_81_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_81_2\" name=\"wpforms[fields][81]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_81_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_81_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_82\">Si oui, o\u00f9 et quand ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" aria-errormessage=\"wpforms-17747-field_82-error\" required><\/div><div id=\"wpforms-17747-field_83-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"83\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous eu un nouveau partenaire sexuel au cours de l&#039;ann\u00e9e \u00e9coul\u00e9e ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_83\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_83_1\" name=\"wpforms[fields][83]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_83_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_83_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_83_2\" name=\"wpforms[fields][83]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_83_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_83_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_84-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"84\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous eu un nouveau partenaire sexuel au cours de l&#039;ann\u00e9e \u00e9coul\u00e9e ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_84\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_84_1\" name=\"wpforms[fields][84]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_84_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_84_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_84_2\" name=\"wpforms[fields][84]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_84_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_84_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_85-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"85\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu des contacts sexuels avec une personne qui s&#039;est av\u00e9r\u00e9e infect\u00e9e par le VIH\/HTLV\/H\u00e9patite\/Lues ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_85\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_85_1\" name=\"wpforms[fields][85]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_85_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_85_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_85_2\" name=\"wpforms[fields][85]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_85_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_85_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Avec quoi ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_86\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_86_1\" name=\"wpforms[fields][86]\" value=\"VIH\" aria-errormessage=\"wpforms-17747-field_86_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_86_1\">VIH<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_86_2\" name=\"wpforms[fields][86]\" value=\"Lues\" aria-errormessage=\"wpforms-17747-field_86_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_86_2\">Lues<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_86_3\" name=\"wpforms[fields][86]\" value=\"H\u00e9patite\" aria-errormessage=\"wpforms-17747-field_86_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_86_3\">H\u00e9patite<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_86_4\" name=\"wpforms[fields][86]\" value=\"HTLV\" aria-errormessage=\"wpforms-17747-field_86_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_86_4\">HTLV<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_86_5\" name=\"wpforms[fields][86]\" value=\"Autre :\" aria-errormessage=\"wpforms-17747-field_86_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_86_5\">Autre :<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_87\">Autre : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_87\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][87]\" aria-errormessage=\"wpforms-17747-field_87-error\" required><\/div><div id=\"wpforms-17747-field_88-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu une maladie sexuellement transmissible (MST) ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_88\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_88_1\" name=\"wpforms[fields][88]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_88_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_88_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_88_2\" name=\"wpforms[fields][88]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_88_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_88_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_89\">Lequel ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_89\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][89]\" aria-errormessage=\"wpforms-17747-field_89-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"7\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-8  \" data-page=\"8\" style=\"display:none;\"><div id=\"wpforms-17747-field_91-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"91\"><div id=\"wpforms-17747-field_91\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_91-error\"><h4>Vaccinations<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_92-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous \u00e9t\u00e9 vaccin\u00e9 (c&#039;est-\u00e0-dire pas une seule injection d&#039;immunoglobuline) contre l&#039;h\u00e9patite A ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_92\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_92_1\" name=\"wpforms[fields][92]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_92_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_92_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_92_2\" name=\"wpforms[fields][92]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_92_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_92_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Le titre \u00e9tait-il suffisant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_94\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_94_1\" name=\"wpforms[fields][94]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_94_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_94_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_94_2\" name=\"wpforms[fields][94]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_94_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_94_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_95-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"95\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous \u00e9t\u00e9 vaccin\u00e9 (c&#039;est-\u00e0-dire pas une seule injection d&#039;immunoglobuline) contre l&#039;h\u00e9patite B ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_95\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_95_1\" name=\"wpforms[fields][95]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_95_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_95_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_95_2\" name=\"wpforms[fields][95]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_95_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_95_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Le titre \u00e9tait-il suffisant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_96\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_96_1\" name=\"wpforms[fields][96]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_96_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_96_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_96_2\" name=\"wpforms[fields][96]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_96_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_96_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_97-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"97\"><fieldset><legend class=\"wpforms-field-label\">Les maladies h\u00e9r\u00e9ditaires sont-elles pr\u00e9sentes dans la famille ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_97\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_97_1\" name=\"wpforms[fields][97]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_97_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_97_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_97_2\" name=\"wpforms[fields][97]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_97_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_97_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_98\">Lesquels ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_98\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][98]\" aria-errormessage=\"wpforms-17747-field_98-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"8\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-9  \" data-page=\"9\" style=\"display:none;\"><div id=\"wpforms-17747-field_100-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"100\"><fieldset><legend class=\"wpforms-field-label\">Quel type de selles avez-vous ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_100\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_1\" name=\"wpforms[fields][100]\" value=\"Type 1\" aria-errormessage=\"wpforms-17747-field_100_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_1\">Type 1<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_2\" name=\"wpforms[fields][100]\" value=\"Type 2\" aria-errormessage=\"wpforms-17747-field_100_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_2\">Type 2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_3\" name=\"wpforms[fields][100]\" value=\"Type 3\" aria-errormessage=\"wpforms-17747-field_100_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_3\">Type 3<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_4\" name=\"wpforms[fields][100]\" value=\"Type 4\" aria-errormessage=\"wpforms-17747-field_100_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_4\">Type 4<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_5\" name=\"wpforms[fields][100]\" value=\"Type 5\" aria-errormessage=\"wpforms-17747-field_100_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_5\">Type 5<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_6\" name=\"wpforms[fields][100]\" value=\"Type 6\" aria-errormessage=\"wpforms-17747-field_100_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_6\">Type 6<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_100_7\" name=\"wpforms[fields][100]\" value=\"Type 7\" aria-errormessage=\"wpforms-17747-field_100_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_100_7\">Type 7<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_101-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"101\"><div id=\"wpforms-17747-field_101\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_101-error\"><h4>Sant\u00e9 intestinale<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_102-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"102\"><div id=\"wpforms-17747-field_102\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-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-17747-field_103-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"103\"><label class=\"wpforms-field-label\" for=\"wpforms-17747-field_103\">Combien de fois par jour allez-vous \u00e0 la selle en moyenne ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_103\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][103]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_103-error\" required><\/div><div id=\"wpforms-17747-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\">Vos selles sont-elles r\u00e9guli\u00e8res ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_105\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_105_1\" name=\"wpforms[fields][105]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_105_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_105_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_105_2\" name=\"wpforms[fields][105]\" value=\"No\" aria-errormessage=\"wpforms-17747-field_105_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_105_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Souffrez-vous de flatulences quotidiennes excessives ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_106\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_106_1\" name=\"wpforms[fields][106]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_106_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_106_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_106_2\" name=\"wpforms[fields][106]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_106_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_106_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_107\">Si oui, \u00e0 quelle fr\u00e9quence cela se produit-il en moyenne par jour ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_107\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][107]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_107-error\" required><\/div><div id=\"wpforms-17747-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\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 trait\u00e9 pour une infection intestinale ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_108\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_108_1\" name=\"wpforms[fields][108]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_108_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_108_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_108_2\" name=\"wpforms[fields][108]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_108_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_108_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_109\">Quand \u00e9tait-ce la derni\u00e8re fois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-17747-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-17747-field_109-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-17747-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\">Souffrez-vous d&#039;une maladie intestinale chronique ?  (par exemple, maladie de Crohn\/colite ulc\u00e9reuse\/maladie c\u0153liaque)     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_110\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_110_1\" name=\"wpforms[fields][110]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_110_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_110_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_110_2\" name=\"wpforms[fields][110]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_110_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_110_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_111\">Si oui, lequel ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_111\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][111]\" aria-errormessage=\"wpforms-17747-field_111-error\" required><\/div><div id=\"wpforms-17747-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\">Vous arrive-t-il de boire des produits sp\u00e9cialement con\u00e7us pour vos selles ?  (activit\u00e9s\/yakult\/actimel etc ?)       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_112\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_112_1\" name=\"wpforms[fields][112]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_112_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_112_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_112_2\" name=\"wpforms[fields][112]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_112_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_112_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_113\">Combien de fois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_113\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][113]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_113-error\" aria-describedby=\"wpforms-17747-field_113-description\" required><div id=\"wpforms-17747-field_113-description\" class=\"wpforms-field-description\">... fois par jour<\/div><\/div><div id=\"wpforms-17747-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\">Souffrez-vous parfois (plus d&#039;une fois par mois) de difficult\u00e9s \u00e0 aller \u00e0 la selle (constipation) qui vous obligent \u00e0 faire un long effort pour \u00e9vacuer les selles ?   <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_114\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_114_1\" name=\"wpforms[fields][114]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_114_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_114_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_114_2\" name=\"wpforms[fields][114]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_114_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_114_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_115\">Si oui, quelle est la fr\u00e9quence moyenne par mois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_115\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][115]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_115-error\" aria-describedby=\"wpforms-17747-field_115-description\" required><div id=\"wpforms-17747-field_115-description\" class=\"wpforms-field-description\">... fois<\/div><\/div><div id=\"wpforms-17747-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\">Souffrez-vous d&#039;h\u00e9morro\u00efdes ?                  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_116\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_116_1\" name=\"wpforms[fields][116]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_116_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_116_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_116_2\" name=\"wpforms[fields][116]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_116_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_116_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Avez-vous souvent des crampes intestinales ?     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_117\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_117_1\" name=\"wpforms[fields][117]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_117_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_117_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_117_2\" name=\"wpforms[fields][117]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_117_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_117_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Prenez-vous des m\u00e9dicaments pour faciliter ou ralentir le transit intestinal ?          <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_118\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_118_1\" name=\"wpforms[fields][118]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_118_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_118_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_118_2\" name=\"wpforms[fields][118]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_118_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_118_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Vous arrive-t-il de prendre certains aliments (prunes\/fibres) pour faciliter le transit intestinal ? pour le soulager ?      <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_119\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_119_1\" name=\"wpforms[fields][119]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_119_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_119_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_119_2\" name=\"wpforms[fields][119]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_119_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_119_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Les troubles intestinaux sont-ils fr\u00e9quents dans votre famille ?               <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_120\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_120_1\" name=\"wpforms[fields][120]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_120_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_120_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_120_2\" name=\"wpforms[fields][120]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_120_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_120_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_122\">Si oui, lesquels et avec qui ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-17747-field_122\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][122]\" aria-errormessage=\"wpforms-17747-field_122-error\" required><\/textarea><\/div><div id=\"wpforms-17747-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\">Y a-t-il des cas de cancer du c\u00f4lon ou de polypes dans votre famille ?       <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_123\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_123_1\" name=\"wpforms[fields][123]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_123_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_123_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_123_2\" name=\"wpforms[fields][123]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_123_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_123_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_124\">Avec qui ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_124\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][124]\" aria-errormessage=\"wpforms-17747-field_124-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_125\">A quel \u00e2ge ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-17747-field_125\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][125]\" step=\"any\" aria-errormessage=\"wpforms-17747-field_125-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"9\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-10  \" data-page=\"10\" style=\"display:none;\"><div id=\"wpforms-17747-field_127-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"127\"><div id=\"wpforms-17747-field_127\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_127-error\"><h4>Utilisation d'antibiotiques<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_128-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"128\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 pris des antibiotiques ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_128\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_128_1\" name=\"wpforms[fields][128]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_128_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_128_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_128_2\" name=\"wpforms[fields][128]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_128_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_128_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Avez-vous pris des antibiotiques au cours des trois derniers mois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_129\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_129_1\" name=\"wpforms[fields][129]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_129_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_129_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_129_2\" name=\"wpforms[fields][129]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_129_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_129_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_131\">Pouvez-vous vous souvenir de l&#039;antibiotique en question ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_131\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][131]\" aria-errormessage=\"wpforms-17747-field_131-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_132\">Quand et pendant combien de jours ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_132\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][132]\" aria-errormessage=\"wpforms-17747-field_132-error\" required><\/div><div id=\"wpforms-17747-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\">Avez-vous utilis\u00e9 des antibiotiques au cours de l&#039;ann\u00e9e \u00e9coul\u00e9e ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_133\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_133_1\" name=\"wpforms[fields][133]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_133_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_133_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_133_2\" name=\"wpforms[fields][133]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_133_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_133_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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-17747-field_134\">Pouvez-vous vous souvenir de l&#039;antibiotique en question ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_134\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][134]\" aria-errormessage=\"wpforms-17747-field_134-error\" required><\/div><div id=\"wpforms-17747-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-17747-field_135\">Quand et pendant combien de jours ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-17747-field_135\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][135]\" aria-errormessage=\"wpforms-17747-field_135-error\" required><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"10\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-11  \" data-page=\"11\" style=\"display:none;\"><div id=\"wpforms-17747-field_137-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"137\"><div id=\"wpforms-17747-field_137\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-17747-field_137-error\"><h4>Autres questions de sant\u00e9<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-17747-field_138-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"138\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 eu des saignements rectaux ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_138\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_138_1\" name=\"wpforms[fields][138]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_138_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_138_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_138_2\" name=\"wpforms[fields][138]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_138_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_138_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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\">Des recherches suppl\u00e9mentaires ont-elles \u00e9t\u00e9 effectu\u00e9es ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_140\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_140_1\" name=\"wpforms[fields][140]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_140_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_140_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_140_2\" name=\"wpforms[fields][140]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_140_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_140_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_141-container\" class=\"wpforms-field wpforms-field-textarea 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value=\"Oui\" aria-errormessage=\"wpforms-17747-field_142_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_142_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_142_2\" name=\"wpforms[fields][142]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_142_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_142_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-field_143-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"143\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous eu la diarrh\u00e9e au cours des 3 derniers mois ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_143\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_143_1\" name=\"wpforms[fields][143]\" 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name=\"wpforms[fields][144]\" aria-errormessage=\"wpforms-17747-field_144-error\" required><\/textarea><\/div><div id=\"wpforms-17747-field_145-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"145\"><fieldset><legend class=\"wpforms-field-label\">Souffrez-vous d&#039;allergies ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-17747-field_145\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_145_1\" name=\"wpforms[fields][145]\" value=\"Oui\" aria-errormessage=\"wpforms-17747-field_145_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_145_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-17747-field_145_2\" name=\"wpforms[fields][145]\" value=\"Non\" aria-errormessage=\"wpforms-17747-field_145_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-17747-field_145_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-17747-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=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"11\" data-formid=\"17747\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-12 last \" data-page=\"12\" style=\"display:none;\"><div id=\"wpforms-17747-field_147-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"147\"><div id=\"wpforms-17747-field_147\" 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