{"id":39325,"date":"2025-10-04T18:10:29","date_gmt":"2025-10-04T11:10:29","guid":{"rendered":"https:\/\/novoscuba.com\/?page_id=39325"},"modified":"2025-12-04T11:56:47","modified_gmt":"2025-12-04T04:56:47","slug":"medical","status":"publish","type":"page","link":"https:\/\/novoscuba.com\/es\/medical\/","title":{"rendered":"Formulario m\u00e9dico"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"39325\" class=\"elementor elementor-39325\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1cf6305 e-flex e-con-boxed e-con e-parent\" data-id=\"1cf6305\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ef9637d elementor-widget elementor-widget-shortcode\" data-id=\"ef9637d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_11 ffs_default_wrap'><form data-form_id=\"11\" id=\"fluentform_11\" class=\"frm-fluent-form fluent_form_11 ff-el-form-top ff_form_instance_11_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_11_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">NovoScuba Medical Statement GB<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='39325' \/><input type=\"hidden\" id=\"_fluentform_11_fluentformnonce\" name=\"_fluentform_11_fluentformnonce\" value=\"6a5a05dfac\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/39325\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-11_1\" ><h1 style=\"text-align: center\">NovoScuba Medical Statement<\/h1><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-11_2\" ><div class=\"ff-el-group  ff-custom_html\" data-name=\"custom_html-80_1\">Recreational scuba diving and freediving requires good physical and mental health. There are a few medical conditions which can be hazardous while diving, listed below. Those who have, or are predisposed to, any of these conditions, should be evaluated by a physician. This Diver Medical Participant Questionnaire provides a basis to determine if you should seek out that evaluation. If you have any concerns about your diving fitness not represented on this form, consult with your physician before diving.<\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-11_3\" ><div class=\"ff-el-group  ff-custom_html\" data-name=\"custom_html-80_1\">If you are feeling ill, avoid diving. If you think you may have a contagious disease, protect yourself and others by not participating in dive training and\/ or dive activities. References to \u201cdiving\u201d on this form encompass both recreational scuba diving and freediving. This form is principally designed as an initial medical screen for new divers, but is also appropriate for divers taking continuing education. For your safety, and that of others who may dive with you, answer all questions honestly.<\/div>\n<div class=\" ff-field_container ff-name-field-wrapper\" data-type=\"name-element\" data-name=\"name_1\">\n<div class=\"ff-t-container\">\n<div class=\"ff-t-cell \">\n<div class=\"ff-el-group  ff-el-form-top\">\u00a0<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><div data-type=\"name-element\" data-name=\"user_name\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_user_name_first_1_3_' id='label_ff_11_user_name_first_1_3_' >First<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"user_name[first_1_3]\" value=\"\" id=\"ff_11_user_name_first_1_3_\" class=\"ff-el-form-control\" placeholder=\"First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_user_name_last_1_6_' id='label_ff_11_user_name_last_1_6_' >Last<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"user_name[last_1_6]\" value=\"\" id=\"ff_11_user_name_last_1_6_\" class=\"ff-el-form-control\" placeholder=\"Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_user_email' id='label_ff_11_user_email' aria-label=\"User Email\">User Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"user_email\" value=\"\" id=\"ff_11_user_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"user_email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><input type=\"hidden\" name=\"course_id\" value=\"{get:course_id}\" data-name=\"course_id\" ><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_date_of_birth_3' id='label_ff_11_date_of_birth_3' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Usa las flechas para navegar por las fechas. Pulsa Intro para seleccionar una fecha.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' name=\"date_of_birth_3\" type=\"text\" class=\"ff-el-form-control ff-el-datepicker\" id=\"ff_11_date_of_birth_3\" data-name=\"date_of_birth_3\"  aria-invalid='false' aria-required=true><\/div><\/div><input type=\"hidden\" name=\"slug\" value=\"medical\" data-name=\"slug\" ><input type=\"hidden\" name=\"user_id\" value=\"0\" data-name=\"user_id\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-11_4\" >Complete this questionnaire as a prerequisite to a recreational scuba diving or freediving course.\n<B>Note to women: If you are pregnant, or attempting to become pregnant, do not dive.<\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have had problems with my lungs, breathing, heart and\/or blood affecting my normal physical or mental performance.\">I have had problems with my lungs, breathing, heart and\/or blood affecting my normal physical or mental performance.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44_79881a216dc5657f904e501d092c5eec'><input  name=\"i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44\" value=\"Yes\"  id='i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44_79881a216dc5657f904e501d092c5eec' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44_d75dbbc668363cdd0c9c9b311d0f5c6d'><input  name=\"i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44\" value=\"No\"  id='i_have_had_problems_with_my_lungs_breathing_heart_and_or_blood_affecting_my_normal_physical_or_mental_performance_44_d75dbbc668363cdd0c9c9b311d0f5c6d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_5\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_6\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and\/or chronic lung disease.\">Chest surgery, heart surgery, heart valve surgery, an implantable medical device (eg, stent, pacemaker, neurostimulator), pneumothorax, and\/or chronic lung disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47_1f1f29b0511ebd2529078a747cf3816f'><input  name=\"chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47\" value=\"Yes\"  id='chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47_1f1f29b0511ebd2529078a747cf3816f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47_c986e6e0992023d75c0935d7713501b0'><input  name=\"chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47\" value=\"No\"  id='chest_surgery_heart_surgery_heart_valve_surgery_an_implantable_medical_device_eg_stent_pacemaker_neurostimulator_pneumothorax_and_or_chronic_lung_disease_47_c986e6e0992023d75c0935d7713501b0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise.\">Asthma, wheezing, severe allergies, hay fever or congested airways within the last 12 months that limits my physical activity\/exercise.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45_ad22b9e514d78e88a646badf0c7bf418'><input  name=\"asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45\" value=\"Yes\"  id='asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45_ad22b9e514d78e88a646badf0c7bf418' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45_980b43e8ca8ba7a5a48b0d3564fc140b'><input  name=\"asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45\" value=\"No\"  id='asthma_wheezing_severe_allergies_hay_fever_or_congested_airways_within_the_last_12_months_that_limits_my_physical_activity_exercise_45_980b43e8ca8ba7a5a48b0d3564fc140b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.\">A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, immersion pulmonary edema, heart attack or stroke, OR am taking medication for any heart condition.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48_dd39d9d4a2eee4fe0eda9d61a49274ac'><input  name=\"a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48\" value=\"Yes\"  id='a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48_dd39d9d4a2eee4fe0eda9d61a49274ac' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48_85da21c4a14a132c9771b7e5bab00c36'><input  name=\"a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48\" value=\"No\"  id='a_problem_or_illness_involving_my_heart_such_as_angina_chest_pain_on_exertion_heart_failure_immersion_pulmonary_edema_heart_attack_or_stroke_or_am_taking_medication_for_any_heart_condition_48_85da21c4a14a132c9771b7e5bab00c36' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.\">Recurrent bronchitis and currently coughing within the past 12 months, OR have been diagnosed with emphysema.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50_8bc5d9058da95ef6c333c947cefe4531'><input  name=\"recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50\" value=\"Yes\"  id='recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50_8bc5d9058da95ef6c333c947cefe4531' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50_613b4fd8c5f17a993fd838f926537f1f'><input  name=\"recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50\" value=\"No\"  id='recurrent_bronchitis_and_currently_coughing_within_the_past_12_months_or_have_been_diagnosed_with_emphysema_50_613b4fd8c5f17a993fd838f926537f1f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Symptoms affecting my lungs, breathing, heart and\/or blood in the last 30 days that impair my physical or mental performance\">Symptoms affecting my lungs, breathing, heart and\/or blood in the last 30 days that impair my physical or mental performance<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49_8a84dfdd722dc67da061e4a0da06715f'><input  name=\"symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49\" value=\"Yes\"  id='symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49_8a84dfdd722dc67da061e4a0da06715f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49_c9c88dcc851774efe68b6c4a0daa55d3'><input  name=\"symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49\" value=\"No\"  id='symptoms_affecting_my_lungs_breathing_heart_and_or_blood_in_the_last_30_days_that_impair_my_physical_or_mental_performance_49_c9c88dcc851774efe68b6c4a0daa55d3' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I am over 45 years of age\">I am over 45 years of age<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_over_45_years_of_age_11_8a3f0f77f5777e2e36a3f5a77072424a'><input  name=\"i_am_over_45_years_of_age_11[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_over_45_years_of_age_11\" value=\"Yes\"  id='i_am_over_45_years_of_age_11_8a3f0f77f5777e2e36a3f5a77072424a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_over_45_years_of_age_11_7ad54df686317ed64703d95b16180771'><input  name=\"i_am_over_45_years_of_age_11[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_over_45_years_of_age_11\" value=\"No\"  id='i_am_over_45_years_of_age_11_7ad54df686317ed64703d95b16180771' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_7\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_8\" >I am over 45 years of age and<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I currently smoke or inhale nicotine by other means\">I currently smoke or inhale nicotine by other means<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_currently_smoke_or_inhale_nicotine_by_other_means_12_f73fca6b89273c6e29fc16ae527137b4'><input  name=\"i_currently_smoke_or_inhale_nicotine_by_other_means_12[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_currently_smoke_or_inhale_nicotine_by_other_means_12\" value=\"Yes\"  id='i_currently_smoke_or_inhale_nicotine_by_other_means_12_f73fca6b89273c6e29fc16ae527137b4' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_currently_smoke_or_inhale_nicotine_by_other_means_12_8a0d5744ac54c1f7f74ec17360a10218'><input  name=\"i_currently_smoke_or_inhale_nicotine_by_other_means_12[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_currently_smoke_or_inhale_nicotine_by_other_means_12\" value=\"No\"  id='i_currently_smoke_or_inhale_nicotine_by_other_means_12_8a0d5744ac54c1f7f74ec17360a10218' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have a high cholesterol level.\">I have a high cholesterol level.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_a_high_cholesterol_level_16_6c6079e1c2a21d92fb416ae716b81339'><input  name=\"i_have_a_high_cholesterol_level_16[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_a_high_cholesterol_level_16\" value=\"Yes\"  id='i_have_a_high_cholesterol_level_16_6c6079e1c2a21d92fb416ae716b81339' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_a_high_cholesterol_level_16_0b5dfec267d1a3c7db8567d0cf453a66'><input  name=\"i_have_a_high_cholesterol_level_16[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_a_high_cholesterol_level_16\" value=\"No\"  id='i_have_a_high_cholesterol_level_16_0b5dfec267d1a3c7db8567d0cf453a66' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have high blood pressure.\">I have high blood pressure.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_high_blood_pressure_51_25122334350b4820d0dfb725dd153e1f'><input  name=\"i_have_high_blood_pressure_51[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_high_blood_pressure_51\" value=\"Yes\"  id='i_have_high_blood_pressure_51_25122334350b4820d0dfb725dd153e1f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_high_blood_pressure_51_90c01fbb151ad4343aeb23318c84654a'><input  name=\"i_have_high_blood_pressure_51[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_high_blood_pressure_51\" value=\"No\"  id='i_have_high_blood_pressure_51_90c01fbb151ad4343aeb23318c84654a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease  before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy)\">I have had a close blood relative die suddenly or of cardiac disease or stroke before the age of 50, OR have a family history of heart disease  before age 50 (including abnormal heart rhythms, coronary artery disease or cardiomyopathy)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar_95a229df908194ab6f8382cd429b53cc'><input  name=\"i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar\" class=\"ff-el-form-check-input ff-el-form-check-radio\" type=\"radio\" data-name=\"i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar\" value=\"Yes\"  id='i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar_95a229df908194ab6f8382cd429b53cc' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar_5e6e4994b1ad785e6156c8f0b7b5b30a'><input  name=\"i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar\" class=\"ff-el-form-check-input ff-el-form-check-radio\" type=\"radio\" data-name=\"i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar\" value=\"No\"  id='i_have_had_a_close_blood_relative_die_suddenly_or_of_cardiac_disease_or_stroke_before_the_age_of_50_or_have_a_family_history_of_heart_disease_before_age_50_including_abnormal_heart_rhythms_coronar_5e6e4994b1ad785e6156c8f0b7b5b30a' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I struggle to perform moderate exercise (for example, walk 1.6 kilometer\/one mile in 14 minutes or swim 200 meters\/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.\">I struggle to perform moderate exercise (for example, walk 1.6 kilometer\/one mile in 14 minutes or swim 200 meters\/yards without resting), OR I have been unable to participate in a normal physical activity due to fitness or health reasons within the past 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act_a370c164dfc8ee6603f65035dbe4c272'><input  name=\"i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act\" value=\"Yes\"  id='i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act_a370c164dfc8ee6603f65035dbe4c272' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act_68b219863dcfe49790d8f81c48dd1953'><input  name=\"i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act\" value=\"No\"  id='i_struggle_to_perform_moderate_exercise_for_example_walk_1_6_kilometer_one_mile_in_14_minutes_or_swim_200_meters_yards_without_resting_or_i_have_been_unable_to_participate_in_a_normal_physical_act_68b219863dcfe49790d8f81c48dd1953' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have had problems with my eyes, ears, or nasal passages\/sinuses.\">I have had problems with my eyes, ears, or nasal passages\/sinuses.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52_0d970cedec0039df421bff995f354703'><input  name=\"i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52\" value=\"Yes\"  id='i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52_0d970cedec0039df421bff995f354703' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52_2716cb2808f8b0dcd6ac5ec0defb5687'><input  name=\"i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52\" value=\"No\"  id='i_have_had_problems_with_my_eyes_ears_or_nasal_passages_sinuses_52_2716cb2808f8b0dcd6ac5ec0defb5687' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_9\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_10\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Sinus surgery within the last 6 months.\">Sinus surgery within the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='sinus_surgery_within_the_last_6_months_56_c0aabb03ac6a1528b2d533d832a2e791'><input  name=\"sinus_surgery_within_the_last_6_months_56[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"sinus_surgery_within_the_last_6_months_56\" value=\"Yes\"  id='sinus_surgery_within_the_last_6_months_56_c0aabb03ac6a1528b2d533d832a2e791' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='sinus_surgery_within_the_last_6_months_56_1e0595e0311268401ee0eab2cbc07b99'><input  name=\"sinus_surgery_within_the_last_6_months_56[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"sinus_surgery_within_the_last_6_months_56\" value=\"No\"  id='sinus_surgery_within_the_last_6_months_56_1e0595e0311268401ee0eab2cbc07b99' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Ear disease or ear surgery, hearing loss, or problems with balance.\">Ear disease or ear surgery, hearing loss, or problems with balance.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59_0858e41accfc18fdb414efd298eded3a'><input  name=\"ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59\" value=\"Yes\"  id='ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59_0858e41accfc18fdb414efd298eded3a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59_0007b1ce4582b9c9996d7b5fc1f0dfe5'><input  name=\"ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59\" value=\"No\"  id='ear_disease_or_ear_surgery_hearing_loss_or_problems_with_balance_59_0007b1ce4582b9c9996d7b5fc1f0dfe5' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Recurrent sinusitis within the past 12 months.\">Recurrent sinusitis within the past 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_sinusitis_within_the_past_12_months_60_a7a5f5f8c1187c71d02648cf63d9471a'><input  name=\"recurrent_sinusitis_within_the_past_12_months_60[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_sinusitis_within_the_past_12_months_60\" value=\"Yes\"  id='recurrent_sinusitis_within_the_past_12_months_60_a7a5f5f8c1187c71d02648cf63d9471a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_sinusitis_within_the_past_12_months_60_5dd6368fc6cb2aa775c58243108d03d1'><input  name=\"recurrent_sinusitis_within_the_past_12_months_60[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_sinusitis_within_the_past_12_months_60\" value=\"No\"  id='recurrent_sinusitis_within_the_past_12_months_60_5dd6368fc6cb2aa775c58243108d03d1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Eye surgery within the past 3 months.\">Eye surgery within the past 3 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='eye_surgery_within_the_past_3_months_61_b809cddd17a19ee17b9ba1483429fac7'><input  name=\"eye_surgery_within_the_past_3_months_61[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"eye_surgery_within_the_past_3_months_61\" value=\"Yes\"  id='eye_surgery_within_the_past_3_months_61_b809cddd17a19ee17b9ba1483429fac7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='eye_surgery_within_the_past_3_months_61_4472fb99b64f8f18cb0d946e17c04617'><input  name=\"eye_surgery_within_the_past_3_months_61[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"eye_surgery_within_the_past_3_months_61\" value=\"No\"  id='eye_surgery_within_the_past_3_months_61_4472fb99b64f8f18cb0d946e17c04617' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.\">I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or suffer from persistent neurologic injury or disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63_41d0524993304564d511ac7ad2f0847c'><input  name=\"i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63\" value=\"Yes\"  id='i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63_41d0524993304564d511ac7ad2f0847c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63_e7b20582fafdf94210538be4c569eb60'><input  name=\"i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63\" value=\"No\"  id='i_have_lost_consciousness_had_migraine_headaches_seizures_stroke_significant_head_injury_or_suffer_from_persistent_neurologic_injury_or_disease_63_e7b20582fafdf94210538be4c569eb60' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.\">I have had surgery within the last 12 months, OR I have ongoing problems related to past surgery.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62_4918622d9f2623303e2b1f773548b51a'><input  name=\"i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62\" value=\"Yes\"  id='i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62_4918622d9f2623303e2b1f773548b51a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62_4928aa48fbe5f1abfd745f3f9cc68aa7'><input  name=\"i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62\" value=\"No\"  id='i_have_had_surgery_within_the_last_12_months_or_i_have_ongoing_problems_related_to_past_surgery_62_4928aa48fbe5f1abfd745f3f9cc68aa7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_11\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_12\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Head injury with loss of consciousness within the past 5 years.\">Head injury with loss of consciousness within the past 5 years.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='head_injury_with_loss_of_consciousness_within_the_past_5_years_65_6058140b17d6e776641581aa2fca4eb8'><input  name=\"head_injury_with_loss_of_consciousness_within_the_past_5_years_65[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"head_injury_with_loss_of_consciousness_within_the_past_5_years_65\" value=\"Yes\"  id='head_injury_with_loss_of_consciousness_within_the_past_5_years_65_6058140b17d6e776641581aa2fca4eb8' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='head_injury_with_loss_of_consciousness_within_the_past_5_years_65_72f40d5b46799ae553f7cebd43c427cb'><input  name=\"head_injury_with_loss_of_consciousness_within_the_past_5_years_65[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"head_injury_with_loss_of_consciousness_within_the_past_5_years_65\" value=\"No\"  id='head_injury_with_loss_of_consciousness_within_the_past_5_years_65_72f40d5b46799ae553f7cebd43c427cb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Persistent neurologic injury or disease.\">Persistent neurologic injury or disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='persistent_neurologic_injury_or_disease_69_05eb2c729375e99f2796f399042e6731'><input  name=\"persistent_neurologic_injury_or_disease_69[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"persistent_neurologic_injury_or_disease_69\" value=\"Yes\"  id='persistent_neurologic_injury_or_disease_69_05eb2c729375e99f2796f399042e6731' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='persistent_neurologic_injury_or_disease_69_039eb060dcfb414a17f72f2e44cb5afc'><input  name=\"persistent_neurologic_injury_or_disease_69[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"persistent_neurologic_injury_or_disease_69\" value=\"No\"  id='persistent_neurologic_injury_or_disease_69_039eb060dcfb414a17f72f2e44cb5afc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Recurring migraine headaches within the past 12 months, or take medications to prevent them.\">Recurring migraine headaches within the past 12 months, or take medications to prevent them.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68_0c78dfc03adb5eafe7ee7397c58b1373'><input  name=\"recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68\" value=\"Yes\"  id='recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68_0c78dfc03adb5eafe7ee7397c58b1373' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68_d4ca45b0f5d939250295f855189b9b3a'><input  name=\"recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68\" value=\"No\"  id='recurring_migraine_headaches_within_the_past_12_months_or_take_medications_to_prevent_them_68_d4ca45b0f5d939250295f855189b9b3a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years.\">Blackouts or fainting (full\/partial loss of consciousness) within the last 5 years.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67_1d4972f5f77b34fdabeebbd9f94a234f'><input  name=\"blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67\" value=\"Yes\"  id='blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67_1d4972f5f77b34fdabeebbd9f94a234f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67_857b625c2cc75d36a2c6e006156909d4'><input  name=\"blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67\" value=\"No\"  id='blackouts_or_fainting_full_partial_loss_of_consciousness_within_the_last_5_years_67_857b625c2cc75d36a2c6e006156909d4' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Epilepsy, seizures, or convulsions, OR take medications to prevent them.\">Epilepsy, seizures, or convulsions, OR take medications to prevent them.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66_625549367b8559c89ab4733f04e45811'><input  name=\"epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66\" value=\"Yes\"  id='epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66_625549367b8559c89ab4733f04e45811' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66_e3b9d9293ac7e52552e88aa8dc9034e8'><input  name=\"epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66\" value=\"No\"  id='epilepsy_seizures_or_convulsions_or_take_medications_to_prevent_them_66_e3b9d9293ac7e52552e88aa8dc9034e8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.\">I am currently undergoing treatment (or have required treatment within the last five years) for psychological problems, personality disorder, panic attacks, or an addiction to drugs or alcohol; or, I have been diagnosed with a learning or developmental disability.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i_47c3cb0d484a8faf7a38095dac1ac133'><input  name=\"i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i\" value=\"Yes\"  id='i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i_47c3cb0d484a8faf7a38095dac1ac133' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i_ecb6555fed51f4a6ba14e15b9fa951c6'><input  name=\"i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i\" value=\"No\"  id='i_am_currently_undergoing_treatment_or_have_required_treatment_within_the_last_five_years_for_psychological_problems_personality_disorder_panic_attacks_or_an_addiction_to_drugs_or_alcohol_or_i_ecb6555fed51f4a6ba14e15b9fa951c6' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_13\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_14\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment.\">Behavioral health, mental or psychological problems requiring medical\/psychiatric treatment.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9_6e14c07f7cab7f84d6f49d94a5e87bf7'><input  name=\"behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9\" value=\"Yes\"  id='behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9_6e14c07f7cab7f84d6f49d94a5e87bf7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9_0a7ffa807118d9ef2c5dfc1a875a408f'><input  name=\"behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9\" value=\"No\"  id='behavioral_health_mental_or_psychological_problems_requiring_medical_psychiatric_treatment_9_0a7ffa807118d9ef2c5dfc1a875a408f' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication\/psychiatric treatment.\">Major depression, suicidal ideation, panic attacks, uncontrolled bipolar disorder requiring medication\/psychiatric treatment.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73_c4cd214d76c85c342ca8cf30f81d5e97'><input  name=\"major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73\" value=\"Yes\"  id='major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73_c4cd214d76c85c342ca8cf30f81d5e97' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73_79e88da47fa38a8894058617b7be8c55'><input  name=\"major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73\" value=\"No\"  id='major_depression_suicidal_ideation_panic_attacks_uncontrolled_bipolar_disorder_requiring_medication_psychiatric_treatment_73_79e88da47fa38a8894058617b7be8c55' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Been diagnosed with a mental health condition or a learning\/developmental disorder that requires ongoing care or special accommodation\">Been diagnosed with a mental health condition or a learning\/developmental disorder that requires ongoing care or special accommodation<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74_bab791910b94448ce2aa5ea8827b0c46'><input  name=\"been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74\" value=\"Yes\"  id='been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74_bab791910b94448ce2aa5ea8827b0c46' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74_dce61bc655fc9b39cc5f924f55a478fc'><input  name=\"been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74\" value=\"No\"  id='been_diagnosed_with_a_mental_health_condition_or_a_learning_developmental_disorder_that_requires_ongoing_care_or_special_accommodation_74_dce61bc655fc9b39cc5f924f55a478fc' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"An addiction to drugs or alcohol requiring treatment within the last 5 years.\">An addiction to drugs or alcohol requiring treatment within the last 5 years.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72_66c929f2f0aac2c3d2cbdc4cf71e0707'><input  name=\"an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72\" value=\"Yes\"  id='an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72_66c929f2f0aac2c3d2cbdc4cf71e0707' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72_c2f6b061bf97aaf6f2404e1fb8f8fef1'><input  name=\"an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72\" value=\"No\"  id='an_addiction_to_drugs_or_alcohol_requiring_treatment_within_the_last_5_years_72_c2f6b061bf97aaf6f2404e1fb8f8fef1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have had back problems, hernia, ulcers, or diabetes.\">I have had back problems, hernia, ulcers, or diabetes.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_back_problems_hernia_ulcers_or_diabetes_77_8ded8d88334eb29cb510aadf24b3d965'><input  name=\"i_have_had_back_problems_hernia_ulcers_or_diabetes_77[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_back_problems_hernia_ulcers_or_diabetes_77\" value=\"Yes\"  id='i_have_had_back_problems_hernia_ulcers_or_diabetes_77_8ded8d88334eb29cb510aadf24b3d965' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_back_problems_hernia_ulcers_or_diabetes_77_13c3aca5327007bd64af316b7710a22c'><input  name=\"i_have_had_back_problems_hernia_ulcers_or_diabetes_77[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_back_problems_hernia_ulcers_or_diabetes_77\" value=\"No\"  id='i_have_had_back_problems_hernia_ulcers_or_diabetes_77_13c3aca5327007bd64af316b7710a22c' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_15\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_16\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Recurrent back problems in the last 6 months that limit my everyday activity.\">Recurrent back problems in the last 6 months that limit my everyday activity.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78_9af97fca6085f55caacbf66de750de78'><input  name=\"recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78\" value=\"Yes\"  id='recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78_9af97fca6085f55caacbf66de750de78' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78_53c344ddda4d439132f1375f9e64e7bd'><input  name=\"recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78\" value=\"No\"  id='recurrent_back_problems_in_the_last_6_months_that_limit_my_everyday_activity_78_53c344ddda4d439132f1375f9e64e7bd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Back or spinal surgery within the last 12 months.\">Back or spinal surgery within the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='back_or_spinal_surgery_within_the_last_12_months_82_b83662789d750abc17b7be638baff083'><input  name=\"back_or_spinal_surgery_within_the_last_12_months_82[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"back_or_spinal_surgery_within_the_last_12_months_82\" value=\"Yes\"  id='back_or_spinal_surgery_within_the_last_12_months_82_b83662789d750abc17b7be638baff083' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='back_or_spinal_surgery_within_the_last_12_months_82_7418b0db6385eec53cd9872189f878eb'><input  name=\"back_or_spinal_surgery_within_the_last_12_months_82[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"back_or_spinal_surgery_within_the_last_12_months_82\" value=\"No\"  id='back_or_spinal_surgery_within_the_last_12_months_82_7418b0db6385eec53cd9872189f878eb' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.\">Diabetes, either drug or diet controlled, OR gestational diabetes within the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81_d03e7375a5b4de536017b1405ea6f674'><input  name=\"diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81\" value=\"Yes\"  id='diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81_d03e7375a5b4de536017b1405ea6f674' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81_5886f75c4a03ee608ea7ee591b6eb912'><input  name=\"diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81\" value=\"No\"  id='diabetes_either_drug_or_diet_controlled_or_gestational_diabetes_within_the_last_12_months_81_5886f75c4a03ee608ea7ee591b6eb912' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"An uncorrected hernia that limits my physical abilities.\">An uncorrected hernia that limits my physical abilities.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='an_uncorrected_hernia_that_limits_my_physical_abilities_83_a589d7378dbdd85a0382a8cb46e0557d'><input  name=\"an_uncorrected_hernia_that_limits_my_physical_abilities_83[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"an_uncorrected_hernia_that_limits_my_physical_abilities_83\" value=\"Yes\"  id='an_uncorrected_hernia_that_limits_my_physical_abilities_83_a589d7378dbdd85a0382a8cb46e0557d' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='an_uncorrected_hernia_that_limits_my_physical_abilities_83_a0bb8cc85bbe6dca472712714efb0d1e'><input  name=\"an_uncorrected_hernia_that_limits_my_physical_abilities_83[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"an_uncorrected_hernia_that_limits_my_physical_abilities_83\" value=\"No\"  id='an_uncorrected_hernia_that_limits_my_physical_abilities_83_a0bb8cc85bbe6dca472712714efb0d1e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.\">Active or untreated ulcers, problem wounds, or ulcer surgery within the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80_0bc6cfd1f5a07d3368babadd130361a6'><input  name=\"active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80\" value=\"Yes\"  id='active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80_0bc6cfd1f5a07d3368babadd130361a6' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80_5aba79f729cf956d38cf391dc4a1843a'><input  name=\"active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80\" value=\"No\"  id='active_or_untreated_ulcers_problem_wounds_or_ulcer_surgery_within_the_last_6_months_80_5aba79f729cf956d38cf391dc4a1843a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I have had stomach or intestine problems, including recent diarrhea.\">I have had stomach or intestine problems, including recent diarrhea.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71_1ca49b4a1b8d25eb2fa1ed66fd322de7'><input  name=\"i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71\" value=\"Yes\"  id='i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71_1ca49b4a1b8d25eb2fa1ed66fd322de7' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71_93347543cf36bf6691e84b64a3b60fda'><input  name=\"i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71\" value=\"No\"  id='i_have_had_stomach_or_intestine_problems_including_recent_diarrhea_71_93347543cf36bf6691e84b64a3b60fda' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_17\" ><B>You answered \u2018yes\u2019 to the question above, please complete these additional questions:<B><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-11_18\" >I have\/have had:<\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Ostomy surgery and do not have medical clearance to swim or engage in physical activity.\">Ostomy surgery and do not have medical clearance to swim or engage in physical activity.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10_c804945cafb19b0f2abf4350a4cd6702'><input  name=\"ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10\" value=\"Yes\"  id='ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10_c804945cafb19b0f2abf4350a4cd6702' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10_457f24bdc6fac8b82eec7e6abdd63e46'><input  name=\"ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10\" value=\"No\"  id='ostomy_surgery_and_do_not_have_medical_clearance_to_swim_or_engage_in_physical_activity_10_457f24bdc6fac8b82eec7e6abdd63e46' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Dehydration requiring medical intervention within the last 7 days.\">Dehydration requiring medical intervention within the last 7 days.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dehydration_requiring_medical_intervention_within_the_last_7_days_84_b44d64929625cf6113a10a9ba4efc100'><input  name=\"dehydration_requiring_medical_intervention_within_the_last_7_days_84[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"dehydration_requiring_medical_intervention_within_the_last_7_days_84\" value=\"Yes\"  id='dehydration_requiring_medical_intervention_within_the_last_7_days_84_b44d64929625cf6113a10a9ba4efc100' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='dehydration_requiring_medical_intervention_within_the_last_7_days_84_42bc4b2e1351f7b1783892b368508ac2'><input  name=\"dehydration_requiring_medical_intervention_within_the_last_7_days_84[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"dehydration_requiring_medical_intervention_within_the_last_7_days_84\" value=\"No\"  id='dehydration_requiring_medical_intervention_within_the_last_7_days_84_42bc4b2e1351f7b1783892b368508ac2' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.\">Active or untreated stomach or intestinal ulcers or ulcer surgery within the last 6 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85_82de81c673f5fe13bebaf7bdbe19268a'><input  name=\"active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85\" value=\"Yes\"  id='active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85_82de81c673f5fe13bebaf7bdbe19268a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85_6599ed8c2fd32ff111a1e82ccd96fd61'><input  name=\"active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85\" value=\"No\"  id='active_or_untreated_stomach_or_intestinal_ulcers_or_ulcer_surgery_within_the_last_6_months_85_6599ed8c2fd32ff111a1e82ccd96fd61' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).\">Frequent heartburn, regurgitation, or gastroesophageal reflux disease (GERD).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86_81e1d48d13409f24419ad9865664dd2b'><input  name=\"frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86\" value=\"Yes\"  id='frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86_81e1d48d13409f24419ad9865664dd2b' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86_73e3234ca536fef765631cabee3641e1'><input  name=\"frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86\" value=\"No\"  id='frequent_heartburn_regurgitation_or_gastroesophageal_reflux_disease_gerd_86_73e3234ca536fef765631cabee3641e1' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Active or uncontrolled ulcerative colitis or Crohn\u2019s disease.\">Active or uncontrolled ulcerative colitis or Crohn\u2019s disease.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88_a70e6dcd351fdb5232d4d14aa845ffcd'><input  name=\"active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88\" value=\"Yes\"  id='active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88_a70e6dcd351fdb5232d4d14aa845ffcd' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88_17e1abbe89cd1f917b7d35879a6d216e'><input  name=\"active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88\" value=\"No\"  id='active_or_uncontrolled_ulcerative_colitis_or_crohns_disease_88_17e1abbe89cd1f917b7d35879a6d216e' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"Bariatric surgery within the last 12 months.\">Bariatric surgery within the last 12 months.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='bariatric_surgery_within_the_last_12_months_87_1ade8c1734df6ac10754dd3805604544'><input  name=\"bariatric_surgery_within_the_last_12_months_87[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"bariatric_surgery_within_the_last_12_months_87\" value=\"Yes\"  id='bariatric_surgery_within_the_last_12_months_87_1ade8c1734df6ac10754dd3805604544' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='bariatric_surgery_within_the_last_12_months_87_a8b197512e67964a8c5ca29eab87220b'><input  name=\"bariatric_surgery_within_the_last_12_months_87[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"bariatric_surgery_within_the_last_12_months_87\" value=\"No\"  id='bariatric_surgery_within_the_last_12_months_87_a8b197512e67964a8c5ca29eab87220b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='' id='label_' aria-label=\"I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).\">I am taking prescription medications (with the exception of birth control or anti-malarial drugs other than mefloquine (Lariam).<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25_1b8eb83f51d3f601a1dc2f0bc0012c04'><input  name=\"i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25\" value=\"Yes\"  id='i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25_1b8eb83f51d3f601a1dc2f0bc0012c04' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check'><label class='ff-el-form-check-label' for='i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25_ddc121b681864b67e900bc830f048c05'><input  name=\"i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25[]\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" type=\"checkbox\" data-name=\"i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25\" value=\"No\"  id='i_am_taking_prescription_medications_with_the_exception_of_birth_control_or_anti_malarial_drugs_other_than_mefloquine_lariam_25_ddc121b681864b67e900bc830f048c05' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.' class='ff-el-form-check-label ff_tc_label' for=consent_23_c7dc0b93bbc41734f4a3e3def624f272><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"consent_23\" class=\"ff-el-form-check-input\" data-name=\"consent_23\" id=\"consent_23_c7dc0b93bbc41734f4a3e3def624f272\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'>I have answered all questions honestly, and understand that I accept responsibility for any consequences resulting from any questions I may have answered inaccurately or for my failure to disclose any existing or past health conditions.<\/div><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"I am over 18 years old\">I am over 18 years old<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_f80ab831a1745d849fe84b78f04620be'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Yes\"  id='checkbox_f80ab831a1745d849fe84b78f04620be' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_efabba1ce83dfbace59bcc4bb6efc2a7'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"No\"  id='checkbox_efabba1ce83dfbace59bcc4bb6efc2a7' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Signature\">Signature<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_11' \n            class='fluentform-signature-pad' \n            data-form-id='11'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign Here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_names_first_name_' id='label_ff_11_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" value=\"\" id=\"ff_11_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_names_last_name_' id='label_ff_11_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" value=\"\" id=\"ff_11_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_11_datetime' id='label_ff_11_datetime' aria-label=\"Date \/ Time\">Date \/ Time<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date \/ Time Usa las flechas para navegar por las fechas. Pulsa Intro para seleccionar una fecha.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" value=\"10\/04\/2026\" id=\"ff_11_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><input type=\"hidden\" name=\"hidden_1\" value=\"10\/04\/2026\" data-name=\"hidden_1\" ><input type=\"hidden\" name=\"doctor_required\" value=\"false\" data-name=\"doctor_required\" ><div class='ff-el-group has-conditions ff-hidden'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Medical Required\">Medical Required<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='medical_requires_approval_f381aff6de640aff4b77b851ff4f4d33'><input  type=\"radio\" name=\"medical_requires_approval\" data-name=\"medical_requires_approval\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"1\"  id='medical_requires_approval_f381aff6de640aff4b77b851ff4f4d33' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions ff-hidden'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Guardian approval required\">Guardian approval required<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='guardian_requires_approval_674b5e8a1d66ba5a094284de76dc634a'><input  type=\"checkbox\" name=\"guardian_requires_approval[]\" data-name=\"guardian_requires_approval\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" checked=\"1\" value=\"1\"  id='guardian_requires_approval_674b5e8a1d66ba5a094284de76dc634a' aria-label='Yes' aria-invalid='false' aria-required=false> <span>Yes<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-text-left ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-11_19\" data-name=\"custom_submit_button-11_19\"  aria-label=\"Submit\">Submit<\/button><style>form.fluent_form_11 .wpf_has_custom_css.ff-btn-submit { background-color:#1a7efb;border-color:#1a7efb;color:#ffffff;min-width:100%; }form.fluent_form_11 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#1a7efb;color:#1a7efb;min-width:100%; } <\/style><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><\/div><\/div><input type=\"hidden\" name=\"10001\" value=\"0\" data-name=\"10001\" ><input type=\"hidden\" name=\"10002\" value=\"0\" data-name=\"10002\" ><input type=\"hidden\" name=\"10003\" value=\"0\" data-name=\"10003\" ><\/fieldset><\/form><div id='fluentform_11_errors' class='ff-errors-in-stack ff_form_instance_11_1 ff-form-loading_errors ff_form_instance_11_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_11_1 = {\"id\":\"11\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_11_1\",\"form_id_selector\":\"fluentform_11\",\"rules\":{\"user_name[first_1_3]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is required\"}},\"user_name[middle_1_4]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global\":false,\"global_message\":\"This field is 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