{"id":4824,"date":"2022-02-18T17:53:49","date_gmt":"2022-02-18T17:53:49","guid":{"rendered":"https:\/\/www.harmoniceggtherapy.nl\/?page_id=4824"},"modified":"2025-09-21T17:43:45","modified_gmt":"2025-09-21T17:43:45","slug":"inschrijfformulier","status":"publish","type":"page","link":"https:\/\/www.harmoniceggtherapy.nl\/nl\/inschrijfformulier\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"4824\" class=\"elementor elementor-4824\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section data-pafe-particles=\"5889e53\" data-pafe-particles-options=\"{&quot;quantity&quot;:150,&quot;particles_color&quot;:&quot;#FFFFFF&quot;,&quot;linked_color&quot;:&quot;#FFFFFF&quot;,&quot;hover_effect&quot;:&quot;repulse&quot;,&quot;click_effect&quot;:&quot;repulse&quot;,&quot;particles_shape&quot;:&quot;circle&quot;,&quot;particles_size&quot;:2,&quot;particles_speed&quot;:2,&quot;particles_image&quot;:&quot;https:\\\/\\\/www.harmoniceggtherapy.nl\\\/wp-content\\\/plugins\\\/elementor\\\/assets\\\/images\\\/placeholder.png&quot;,&quot;particles_opacity&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:0.299999999999999988897769753748434595763683319091796875,&quot;sizes&quot;:[]},&quot;linked_opacity&quot;:0.2099999999999999922284388276239042170345783233642578125}\" class=\"elementor-section elementor-top-section elementor-element elementor-element-5889e53 elementor-section-full_width elementor-section-height-min-height gradient-1 elementor-section-height-default elementor-section-items-middle\" data-id=\"5889e53\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;waves&quot;,&quot;shape_divider_bottom_negative&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"true\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 1000 100\" preserveaspectratio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M790.5,93.1c-59.3-5.3-116.8-18-192.6-50c-29.6-12.7-76.9-31-100.5-35.9c-23.6-4.9-52.6-7.8-75.5-5.3\tc-10.2,1.1-22.6,1.4-50.1,7.4c-27.2,6.3-58.2,16.6-79.4,24.7c-41.3,15.9-94.9,21.9-134,22.6C72,58.2,0,25.8,0,25.8V100h1000V65.3\tc0,0-51.5,19.4-106.2,25.7C839.5,97,814.1,95.2,790.5,93.1z\"\/>\n<\/svg>\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-75c886e\" data-id=\"75c886e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-41d170d elementor-widget elementor-widget-heading\" data-id=\"41d170d\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Intake form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7570ae8 elementor-widget elementor-widget-heading\" data-id=\"7570ae8\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Het portaal <em>naar<\/em> <br>Uw welzijn<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-901e134 elementor-widget elementor-widget-heading\" data-id=\"901e134\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Harmoniseer jezelf van binnenuit met behulp van kleuren, geluiden, trillingen en energieresonantie.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9a6a4ef elementor-widget elementor-widget-heading\" data-id=\"9a6a4ef\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Baanbrekende resonantiekamertechnologie voor een betere gezondheid en gemoedstoestand.  <br>Gunstige frequenties voor fysieke &amp; emotionele pijnverlichting, herstel van ziektes, stressniveaubeheer, verlichting bij burn-out, immuniteit &amp; meer. <\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-b4822d7\" data-id=\"b4822d7\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f3dcb3b animated-slow elementor-invisible elementor-widget elementor-widget-image\" data-id=\"f3dcb3b\" data-element_type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;,&quot;_animation_delay&quot;:600}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"893\" height=\"830\" src=\"https:\/\/www.harmoniceggtherapy.nl\/wp-content\/uploads\/2021\/05\/Harmonic-EGG.png\" class=\"attachment-large size-large wp-image-4742\" alt=\"\" srcset=\"https:\/\/www.harmoniceggtherapy.nl\/wp-content\/uploads\/2021\/05\/Harmonic-EGG.png 893w, https:\/\/www.harmoniceggtherapy.nl\/wp-content\/uploads\/2021\/05\/Harmonic-EGG-600x558.png 600w, https:\/\/www.harmoniceggtherapy.nl\/wp-content\/uploads\/2021\/05\/Harmonic-EGG-300x279.png 300w, https:\/\/www.harmoniceggtherapy.nl\/wp-content\/uploads\/2021\/05\/Harmonic-EGG-768x714.png 768w\" sizes=\"(max-width: 893px) 100vw, 893px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e489623 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"e489623\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-78fbd72\" data-id=\"78fbd72\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d642a29 elementor-widget elementor-widget-heading\" data-id=\"d642a29\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Intake Form<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b90e223 elementor-widget elementor-widget-text-editor\" data-id=\"b90e223\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-weight: 400;\">All new clients are asked to complete a detailed history prior to their first visit. This helps determine the best form of treatment. Please fill out the form below before your first appointment.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2c2ddf0 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"2c2ddf0\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-c14582c\" data-id=\"c14582c\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6decd9a elementor-widget elementor-widget-text-editor\" data-id=\"6decd9a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><span style=\"font-weight: 400;\">Your data is protected! We believe your data is your property and support your right to privacy. Your data is not shared with 3rd parties.\u00a0<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6f6f970 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"6f6f970\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Intake Form\" aria-label=\"Intake Form\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"4824\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"6f6f970\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t*Voornaam (verplicht veld)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Voornaam\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-surname elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-surname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t*Achternaam (verplicht veld)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[surname]\" id=\"form-field-surname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Achternaam\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-email elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Date of Birth\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_47572c5 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_47572c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_47572c5]\" id=\"form-field-field_47572c5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Height\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f151da2 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f151da2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeight\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f151da2]\" id=\"form-field-field_f151da2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Weight\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_73f28f5 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_73f28f5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWork\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_73f28f5]\" id=\"form-field-field_73f28f5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Work\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-tel elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tel\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t*Mobile  (required field)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[tel]\" id=\"form-field-tel\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Mobile\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Alleen nummers en telefoontekens (#, -, *, enz.) worden geaccepteerd.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t*Email (verplicht veld)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"E-mail\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b147509 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b147509\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t Street and house\/flat number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b147509]\" id=\"form-field-field_b147509\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\" Street and house\/flat number\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e3be849 elementor-col-75\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3be849\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCity\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e3be849]\" id=\"form-field-field_e3be849\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"City\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_826b5ee elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_826b5ee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostcode\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_826b5ee]\" id=\"form-field-field_826b5ee\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Postcode\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_21bb8aa elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_21bb8aa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmergency Contact\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_21bb8aa]\" id=\"form-field-field_21bb8aa\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Emergency Contact\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4637078 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4637078\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4637078]\" id=\"form-field-field_4637078\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Relation\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_ebbdf51 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ebbdf51\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTelefoon\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_ebbdf51]\" id=\"form-field-field_ebbdf51\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Telefoon\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Alleen nummers en telefoontekens (#, -, *, enz.) worden geaccepteerd.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_84788b8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_84788b8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelation status\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_84788b8]\" id=\"form-field-field_84788b8\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"Single\">Single<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Married\">Married<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Partner\">Partner<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Separated\">Separated<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorced\">Divorced<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widow\">Widow<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widower\">Widower<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_63ff224 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_63ff224\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSpouse\/Partner Name:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_63ff224]\" id=\"form-field-field_63ff224\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_a518e00 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a518e00\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t# of Children\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_a518e00]\" id=\"form-field-field_a518e00\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f98af45 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f98af45\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOccupation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f98af45]\" id=\"form-field-field_f98af45\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8ceaf20 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8ceaf20\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you enjoy your job?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_8ceaf20-0\" name=\"form_fields[field_8ceaf20][]\"> <label for=\"form-field-field_8ceaf20-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_8ceaf20-1\" name=\"form_fields[field_8ceaf20][]\"> <label for=\"form-field-field_8ceaf20-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_1566e08 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1566e08\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPrimary Reason for seeing us:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_1566e08]\" id=\"form-field-field_1566e08\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c6d72dd elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c6d72dd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave others helped you with the problem:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_c6d72dd]\" id=\"form-field-field_c6d72dd\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_4a67593 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a67593\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat are your expectations after the sessions:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_4a67593]\" id=\"form-field-field_4a67593\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_19d9a52 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_19d9a52\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWho can we <strong>thank <\/strong>for your being here (who referred you):\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_19d9a52]\" id=\"form-field-field_19d9a52\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ff2b062 elementor-col-100\">\n\t\t\t\t\t<p><br><br><center><h2><b><i><p style=\"color:darkviolet\">Check the conditions listed below which you have experienced: <br>Select P for over a year ago, C for current or leave blank if not applicable<\/b><\/i><\/p><\/h3><\/center>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_fdbb71b elementor-col-100\">\n\t\t\t\t\tMETABOLISM\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5e41f14 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e41f14\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeight Gain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5e41f14]\" id=\"form-field-field_5e41f14\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_cdb441f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cdb441f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeight Loss\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_cdb441f]\" id=\"form-field-field_cdb441f\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_93bf825 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_93bf825\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeigh\/Low Blood Pressure\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_93bf825]\" id=\"form-field-field_93bf825\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fc5d274 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc5d274\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBlood Sugar\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fc5d274]\" id=\"form-field-field_fc5d274\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_db953d6 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_db953d6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tThyroid\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_db953d6]\" id=\"form-field-field_db953d6\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a0f4241 elementor-col-100\">\n\t\t\t\t\tDENTAL\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c104689 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c104689\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTooth Problems\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c104689]\" id=\"form-field-field_c104689\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6f99a89 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6f99a89\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRoot Canals\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6f99a89]\" id=\"form-field-field_6f99a89\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_83460c5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_83460c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAmalgam Fillings\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_83460c5]\" id=\"form-field-field_83460c5\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8b6ee2c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8b6ee2c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDifficulty chewing\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8b6ee2c]\" id=\"form-field-field_8b6ee2c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9caeb52 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9caeb52\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTMJ\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9caeb52]\" id=\"form-field-field_9caeb52\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9e6bed1 elementor-col-100\">\n\t\t\t\t\tDIGESTION\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_dd5055b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dd5055b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeartburn\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_dd5055b]\" id=\"form-field-field_dd5055b\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_851473c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_851473c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAbdominal Pain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_851473c]\" id=\"form-field-field_851473c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_bb38a10 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bb38a10\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGas\/Bloating\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_bb38a10]\" id=\"form-field-field_bb38a10\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_12dbfc5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12dbfc5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDiarrhea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_12dbfc5]\" id=\"form-field-field_12dbfc5\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b2a44c3 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b2a44c3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tConstipattion\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b2a44c3]\" id=\"form-field-field_b2a44c3\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c1c6c2c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c1c6c2c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBlood in Stool\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c1c6c2c]\" id=\"form-field-field_c1c6c2c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ed7d953 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ed7d953\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHistory of Ulcers\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ed7d953]\" id=\"form-field-field_ed7d953\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fe05d5a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fe05d5a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tColitis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fe05d5a]\" id=\"form-field-field_fe05d5a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a29d436 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a29d436\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLiver Desease\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a29d436]\" id=\"form-field-field_a29d436\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_09d5974 elementor-col-100\">\n\t\t\t\t\tFEMALE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6e5620d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6e5620d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPregnant\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6e5620d]\" id=\"form-field-field_6e5620d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_87ad2e9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_87ad2e9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProblems with periods\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_87ad2e9]\" id=\"form-field-field_87ad2e9\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1d4bdb2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1d4bdb2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCancer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1d4bdb2]\" id=\"form-field-field_1d4bdb2\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8027e43 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8027e43\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBreast Tenderness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8027e43]\" id=\"form-field-field_8027e43\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9b41d40 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9b41d40\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBreast Implants\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9b41d40]\" id=\"form-field-field_9b41d40\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5968b7d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5968b7d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMenopausal Symptoms\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5968b7d]\" id=\"form-field-field_5968b7d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6bfb215 elementor-col-100\">\n\t\t\t\t\tSKIN\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b7d9d55 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b7d9d55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRash\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b7d9d55]\" id=\"form-field-field_b7d9d55\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6419aca elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6419aca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEczema\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6419aca]\" id=\"form-field-field_6419aca\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_272b083 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_272b083\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDry Skin\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_272b083]\" id=\"form-field-field_272b083\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2e0b08d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2e0b08d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAcne\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2e0b08d]\" id=\"form-field-field_2e0b08d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_08d9380 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_08d9380\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRecent Botox\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_08d9380]\" id=\"form-field-field_08d9380\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4bdd657 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4bdd657\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAny recent substance Injection under skin\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4bdd657]\" id=\"form-field-field_4bdd657\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b494300 elementor-col-100\">\n\t\t\t\t\tCHEST\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7232f91 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7232f91\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChest Pain\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7232f91]\" id=\"form-field-field_7232f91\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6417254 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6417254\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPalpitations\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6417254]\" id=\"form-field-field_6417254\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1c033a1 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c033a1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCough\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1c033a1]\" id=\"form-field-field_1c033a1\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_de58314 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_de58314\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tShortness of Breath\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_de58314]\" id=\"form-field-field_de58314\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_017b838 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_017b838\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAsthma\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_017b838]\" id=\"form-field-field_017b838\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c564d77 elementor-col-100\">\n\t\t\t\t\tURINARY\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c68c0ad elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c68c0ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFrequent Urination\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c68c0ad]\" id=\"form-field-field_c68c0ad\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7b2144f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b2144f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDifficulty starting Urination\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7b2144f]\" id=\"form-field-field_7b2144f\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2e0e772 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2e0e772\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUrinary Incontinence\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2e0e772]\" id=\"form-field-field_2e0e772\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7447ba4 elementor-col-100\">\n\t\t\t\t\tSTRUCTURAL\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3e8dc4c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3e8dc4c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tArthritis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3e8dc4c]\" id=\"form-field-field_3e8dc4c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_61f91d0 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_61f91d0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBursitis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_61f91d0]\" id=\"form-field-field_61f91d0\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d86afcb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d86afcb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOsteoporosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_d86afcb]\" id=\"form-field-field_d86afcb\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_489f61e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_489f61e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFoot\/Ancle Swelling\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_489f61e]\" id=\"form-field-field_489f61e\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0ce37d3 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0ce37d3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBlood Clots\/Phlebitis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0ce37d3]\" id=\"form-field-field_0ce37d3\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_506d1c2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_506d1c2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVaricose Veins\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_506d1c2]\" id=\"form-field-field_506d1c2\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3c37b6c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c37b6c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRecent Surgery\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3c37b6c]\" id=\"form-field-field_3c37b6c\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a13bc39 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a13bc39\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNeck Pain\/Problems\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a13bc39]\" id=\"form-field-field_a13bc39\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_64cdfcd elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_64cdfcd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBack Pain\/Problems\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_64cdfcd]\" id=\"form-field-field_64cdfcd\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4d72f3a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4d72f3a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSciatica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4d72f3a]\" id=\"form-field-field_4d72f3a\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8073295 elementor-col-100\">\n\t\t\t\t\tEYES\/EARS\/MOUTH\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1f396ba elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f396ba\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHeadaches\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1f396ba]\" id=\"form-field-field_1f396ba\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a6c1d07 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6c1d07\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDizziness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a6c1d07]\" id=\"form-field-field_a6c1d07\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_002f577 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_002f577\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRinging in Ears\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_002f577]\" id=\"form-field-field_002f577\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ba800e3 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba800e3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tBlurred Vision\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ba800e3]\" id=\"form-field-field_ba800e3\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1514635 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1514635\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSinus Problems\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1514635]\" id=\"form-field-field_1514635\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_416d61d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_416d61d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDifficulty Swallowing\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_416d61d]\" id=\"form-field-field_416d61d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_dbfe931 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dbfe931\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMouth Sores\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_dbfe931]\" id=\"form-field-field_dbfe931\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7475a35 elementor-col-100\">\n\t\t\t\t\tNEUROLOGIC\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8362daa elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8362daa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNumbness or Tingling\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8362daa]\" id=\"form-field-field_8362daa\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9d0590d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9d0590d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWeakness\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9d0590d]\" id=\"form-field-field_9d0590d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a6aefd7 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6aefd7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSlapeloosheid\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a6aefd7]\" id=\"form-field-field_a6aefd7\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_baaad30 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_baaad30\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPoor Balance\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_baaad30]\" id=\"form-field-field_baaad30\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1f7af15 elementor-col-100\">\n\t\t\t\t\tMALE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ee061bd elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ee061bd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tProstate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ee061bd]\" id=\"form-field-field_ee061bd\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5d9ad6e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5d9ad6e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCancer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5d9ad6e]\" id=\"form-field-field_5d9ad6e\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c643930 elementor-col-100\">\n\t\t\t\t\tALLERGIES\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4b2dc61 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b2dc61\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedications\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4b2dc61]\" id=\"form-field-field_4b2dc61\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5eaedc1 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5eaedc1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChemicals\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5eaedc1]\" id=\"form-field-field_5eaedc1\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6de8fef elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6de8fef\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFoods\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6de8fef]\" id=\"form-field-field_6de8fef\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_79addc9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_79addc9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlants\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_79addc9]\" id=\"form-field-field_79addc9\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_3a0acc5 elementor-col-100\">\n\t\t\t\t\tIMMUNE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_60fa6e4 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_60fa6e4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChronic Fatigue\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_60fa6e4]\" id=\"form-field-field_60fa6e4\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e3fb277 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3fb277\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFibromyalgie\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e3fb277]\" id=\"form-field-field_e3fb277\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_85f6380 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_85f6380\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tYeast Infections\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_85f6380]\" id=\"form-field-field_85f6380\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8c31e5d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8c31e5d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPast Viral Infections\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8c31e5d]\" id=\"form-field-field_8c31e5d\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_70721af elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_70721af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPast Strep or Mono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_70721af]\" id=\"form-field-field_70721af\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b4ea0e9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b4ea0e9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEpstein-Barr\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b4ea0e9]\" id=\"form-field-field_b4ea0e9\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7bf27b7 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7bf27b7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLyme\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7bf27b7]\" id=\"form-field-field_7bf27b7\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"P\">P<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"C\">C<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a624a27 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a624a27\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMedications, Herbs, Supplements (list name, dose, and purpose)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_a624a27]\" id=\"form-field-field_a624a27\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_3c1f76c elementor-col-100\">\n\t\t\t\t\tWe recommend drinking  2.5 - 3.5 liters of water daily starting on the day before your first session and for\nthe days of integration.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_7af925c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7af925c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you expect any difficulty with this?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_7af925c-0\" name=\"form_fields[field_7af925c][]\"> <label for=\"form-field-field_7af925c-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_7af925c-1\" name=\"form_fields[field_7af925c][]\"> <label for=\"form-field-field_7af925c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_e3227d4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3227d4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tExplain:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_e3227d4]\" id=\"form-field-field_e3227d4\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_910d981 elementor-col-100\">\n\t\t\t\t\t<b>How much do you use per week?<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_ce24bdd elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ce24bdd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAlcohol\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_ce24bdd]\" id=\"form-field-field_ce24bdd\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_c6395b3 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c6395b3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTobacco\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_c6395b3]\" id=\"form-field-field_c6395b3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_8612d4c elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8612d4c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCoffee\/Tea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_8612d4c]\" id=\"form-field-field_8612d4c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_664d73a elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_664d73a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDrugs\/Marijuana\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_664d73a]\" id=\"form-field-field_664d73a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_335cd27 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_335cd27\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInjuries\/Accidents?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_335cd27-0\" name=\"form_fields[field_335cd27][]\"> <label for=\"form-field-field_335cd27-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_335cd27-1\" name=\"form_fields[field_335cd27][]\"> <label for=\"form-field-field_335cd27-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f6f89af elementor-col-75\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f6f89af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhen & Describe\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f6f89af]\" id=\"form-field-field_f6f89af\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_51f5378 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_51f5378\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTraumatic life events leading to any illness:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_51f5378]\" id=\"form-field-field_51f5378\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f3a0c18 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f3a0c18\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tToxic Exposures:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f3a0c18]\" id=\"form-field-field_f3a0c18\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_280733c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_280733c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe other medical conditions  that we should be aware of:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_280733c]\" id=\"form-field-field_280733c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_5963f70 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_5963f70-0\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-0\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Problems\" id=\"form-field-field_5963f70-1\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-1\">Heart Problems<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stroke\" id=\"form-field-field_5963f70-2\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-2\">Stroke<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Seizures\" id=\"form-field-field_5963f70-3\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-3\">Seizures<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_5963f70-4\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-4\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"MS\" id=\"form-field-field_5963f70-5\" name=\"form_fields[field_5963f70][]\"> <label for=\"form-field-field_5963f70-5\">MS<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_55abe23 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_55abe23\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_55abe23]\" id=\"form-field-field_55abe23\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_ae6089d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ae6089d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAreas in body of complaint or tension:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_ae6089d]\" id=\"form-field-field_ae6089d\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_7600c2e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7600c2e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSurgeries with dates (include location of metal plates\/rods\/screws)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_7600c2e]\" id=\"form-field-field_7600c2e\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_517f384 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_517f384\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFamily  midical history\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_517f384-0\" name=\"form_fields[field_517f384][]\"> <label for=\"form-field-field_517f384-0\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Problems\" id=\"form-field-field_517f384-1\" name=\"form_fields[field_517f384][]\"> <label for=\"form-field-field_517f384-1\">Heart Problems<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High Blood Pressure\" id=\"form-field-field_517f384-2\" name=\"form_fields[field_517f384][]\"> <label for=\"form-field-field_517f384-2\">High Blood Pressure<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_517f384-3\" name=\"form_fields[field_517f384][]\"> <label for=\"form-field-field_517f384-3\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Alzheimer&#039;s\" id=\"form-field-field_517f384-4\" name=\"form_fields[field_517f384][]\"> <label for=\"form-field-field_517f384-4\">Alzheimer's<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ec1d8d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ec1d8d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOther\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ec1d8d]\" id=\"form-field-field_3ec1d8d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f269adc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f269adc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent Pain Level (1=very low, 5=very high): 1 2 3 4 5 Explain:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f269adc]\" id=\"form-field-field_f269adc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f3e9231 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f3e9231\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent Stress Level (1=very low, 5=very high): 1 2 3 4 5 Explain:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f3e9231]\" id=\"form-field-field_f3e9231\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b7d9b56 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b7d9b56\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCurrent Energy Level (1=very low, 5=very high): 1 2 3 4 5 Explain:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b7d9b56]\" id=\"form-field-field_b7d9b56\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c45098c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c45098c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe any specific medical attention or assistance you will need while visiting our center (you must be able to get into the unit or bring a caregiver to help you).\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_c45098c]\" id=\"form-field-field_c45098c\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6c82cf6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6c82cf6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWill you be bringing a caregiver, nurse or spouse with you?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6c82cf6]\" id=\"form-field-field_6c82cf6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a9debd6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a9debd6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease select the checkbox of the word that best describes your current state of health:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Excellent\" id=\"form-field-field_a9debd6-0\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-0\">Excellent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Good\" id=\"form-field-field_a9debd6-1\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-1\">Good<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Average\" id=\"form-field-field_a9debd6-2\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-2\">Average<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Improving\" id=\"form-field-field_a9debd6-3\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-3\">Improving<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Declining\" id=\"form-field-field_a9debd6-4\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-4\">Declining<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Serious\" id=\"form-field-field_a9debd6-5\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-5\">Serious<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Debiliated\" id=\"form-field-field_a9debd6-6\" name=\"form_fields[field_a9debd6][]\"> <label for=\"form-field-field_a9debd6-6\">Debiliated<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_4617453 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4617453\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat brings you joy?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_4617453]\" id=\"form-field-field_4617453\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_bc59ba1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bc59ba1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPlease check the box of the most emotional draining relationship or relationship in your life:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"A spouse or one in a similar relationship\" id=\"form-field-field_bc59ba1-0\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-0\">A spouse or one in a similar relationship<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Parent\" id=\"form-field-field_bc59ba1-1\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-1\">Parent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Job\" id=\"form-field-field_bc59ba1-2\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-2\">Job<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Children\" id=\"form-field-field_bc59ba1-3\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-3\">Children<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Your Relationship with Yourself\" id=\"form-field-field_bc59ba1-4\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-4\">Your Relationship with Yourself<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"State of the World\" id=\"form-field-field_bc59ba1-5\" name=\"form_fields[field_bc59ba1][]\"> <label for=\"form-field-field_bc59ba1-5\">State of the World<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0b45414 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0b45414\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs your home environment peaceful  or stressful most of the time?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0b45414]\" id=\"form-field-field_0b45414\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_df476dc elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_df476dc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have trouble concentrating, or \u2018brain fog\u2019?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_df476dc-0\" name=\"form_fields[field_df476dc][]\"> <label for=\"form-field-field_df476dc-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_df476dc-1\" name=\"form_fields[field_df476dc][]\"> <label for=\"form-field-field_df476dc-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c0e1356 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c0e1356\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you feel supported?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_c0e1356-0\" name=\"form_fields[field_c0e1356][]\"> <label for=\"form-field-field_c0e1356-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_c0e1356-1\" name=\"form_fields[field_c0e1356][]\"> <label for=\"form-field-field_c0e1356-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d81f3b4 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d81f3b4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhat drives you, inspires you, gives you a sense of purpose:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_d81f3b4]\" id=\"form-field-field_d81f3b4\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6694487 elementor-col-100\">\n\t\t\t\t\tPlease check the emotions that best reflect how you feel most of the time:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_055b000 elementor-col-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"JOY\" id=\"form-field-field_055b000-0\" name=\"form_fields[field_055b000][]\"> <label for=\"form-field-field_055b000-0\">JOY<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anger\" id=\"form-field-field_055b000-1\" name=\"form_fields[field_055b000][]\"> <label for=\"form-field-field_055b000-1\">Anger<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Resentent\" id=\"form-field-field_055b000-2\" name=\"form_fields[field_055b000][]\"> <label for=\"form-field-field_055b000-2\">Resentent<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Peaceful\" id=\"form-field-field_055b000-3\" name=\"form_fields[field_055b000][]\"> <label for=\"form-field-field_055b000-3\">Peaceful<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Happy\" id=\"form-field-field_055b000-4\" name=\"form_fields[field_055b000][]\"> <label for=\"form-field-field_055b000-4\">Happy<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8e15a12 elementor-col-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sad\" id=\"form-field-field_8e15a12-0\" name=\"form_fields[field_8e15a12][]\"> <label for=\"form-field-field_8e15a12-0\">Sad<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Depressed\" id=\"form-field-field_8e15a12-1\" name=\"form_fields[field_8e15a12][]\"> <label for=\"form-field-field_8e15a12-1\">Depressed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hopeless\" id=\"form-field-field_8e15a12-2\" name=\"form_fields[field_8e15a12][]\"> <label for=\"form-field-field_8e15a12-2\">Hopeless<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Despair\" id=\"form-field-field_8e15a12-3\" name=\"form_fields[field_8e15a12][]\"> <label for=\"form-field-field_8e15a12-3\">Despair<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Blissful\" id=\"form-field-field_8e15a12-4\" name=\"form_fields[field_8e15a12][]\"> <label for=\"form-field-field_8e15a12-4\">Blissful<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_889002d elementor-col-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Excited\" id=\"form-field-field_889002d-0\" name=\"form_fields[field_889002d][]\"> <label for=\"form-field-field_889002d-0\">Excited<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Passionate\" id=\"form-field-field_889002d-1\" name=\"form_fields[field_889002d][]\"> <label for=\"form-field-field_889002d-1\">Passionate<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Safe\" id=\"form-field-field_889002d-2\" name=\"form_fields[field_889002d][]\"> <label for=\"form-field-field_889002d-2\">Safe<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Calm\" id=\"form-field-field_889002d-3\" name=\"form_fields[field_889002d][]\"> <label for=\"form-field-field_889002d-3\">Calm<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Afraid\" id=\"form-field-field_889002d-4\" name=\"form_fields[field_889002d][]\"> <label for=\"form-field-field_889002d-4\">Afraid<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9b37346 elementor-col-25\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Optimistic\" id=\"form-field-field_9b37346-0\" name=\"form_fields[field_9b37346][]\"> <label for=\"form-field-field_9b37346-0\">Optimistic<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Terrified\" id=\"form-field-field_9b37346-1\" name=\"form_fields[field_9b37346][]\"> <label for=\"form-field-field_9b37346-1\">Terrified<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anxious\" id=\"form-field-field_9b37346-2\" name=\"form_fields[field_9b37346][]\"> <label for=\"form-field-field_9b37346-2\">Anxious<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Alone\" id=\"form-field-field_9b37346-3\" name=\"form_fields[field_9b37346][]\"> <label for=\"form-field-field_9b37346-3\">Alone<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Frustrated\" id=\"form-field-field_9b37346-4\" name=\"form_fields[field_9b37346][]\"> <label for=\"form-field-field_9b37346-4\">Frustrated<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_38a2860 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38a2860\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you adhere to any particular diet? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38a2860]\" id=\"form-field-field_38a2860\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_366c4c1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_366c4c1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow many hours of sleep do you get on average?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_366c4c1]\" id=\"form-field-field_366c4c1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_c441a27 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c441a27\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you drink filtered or purified water?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_c441a27-0\" name=\"form_fields[field_c441a27][]\"> <label for=\"form-field-field_c441a27-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_c441a27-1\" name=\"form_fields[field_c441a27][]\"> <label for=\"form-field-field_c441a27-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7981c8d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7981c8d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDescribe your exercise\/activity routine:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7981c8d]\" id=\"form-field-field_7981c8d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e7f32ea elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e7f32ea\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you sensitive to light \/ loud noise?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_e7f32ea-0\" name=\"form_fields[field_e7f32ea][]\"> <label for=\"form-field-field_e7f32ea-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_e7f32ea-1\" name=\"form_fields[field_e7f32ea][]\"> <label for=\"form-field-field_e7f32ea-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_34764ad elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_34764ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf  Yes, Please  explain:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_34764ad]\" id=\"form-field-field_34764ad\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a4a1f54 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a4a1f54\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you consider yourself a highly sensitive person (HSP) ?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a4a1f54]\" id=\"form-field-field_a4a1f54\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f288bf0 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f288bf0\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you in fear regarding your health?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f288bf0]\" id=\"form-field-field_f288bf0\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_df0a483 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_df0a483\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRegaining well being requires a strong personal commitment. How ready are you to make the lifestyle changes, the diet changes and the attitude changes that may be necessary to good health?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ready\" id=\"form-field-field_df0a483-0\" name=\"form_fields[field_df0a483][]\"> <label for=\"form-field-field_df0a483-0\">Ready<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Somewhat\" id=\"form-field-field_df0a483-1\" name=\"form_fields[field_df0a483][]\"> <label for=\"form-field-field_df0a483-1\">Somewhat<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Not looking to make changes\" id=\"form-field-field_df0a483-2\" name=\"form_fields[field_df0a483][]\"> <label for=\"form-field-field_df0a483-2\">Not looking to make changes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Stuur<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"nl\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-259e1ce elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"259e1ce\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ff8903d\" data-id=\"ff8903d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-94aa389 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"94aa389\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-float\" href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/home-eng\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"icon icon-arrow-right\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Terug naar huis ENG<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-99e649e elementor-align-center elementor-widget elementor-widget-button\" data-id=\"99e649e\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-float\" href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"icon icon-arrow-right\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Terug naar Home NL<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7e5b163 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"7e5b163\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-bddc540\" data-id=\"bddc540\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a2b97cc elementor-view-stacked elementor-shape-circle elementor-position-top elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"a2b97cc\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<a href=\"https:\/\/www.instagram.com\/harmoniceggtherapy\/\" target=\"_blank\" class=\"elementor-icon elementor-animation-grow\" tabindex=\"-1\" aria-label=\"Bezoek onze pagina \u2192\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fab fa-instagram\"><\/i>\t\t\t\t<\/a>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/www.instagram.com\/harmoniceggtherapy\/\" target=\"_blank\" >\n\t\t\t\t\t\t\tBezoek onze pagina \u2192\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tInstagram Berichten\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-d949f18\" data-id=\"d949f18\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c359a77 elementor-view-stacked elementor-shape-circle elementor-position-top elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"c359a77\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/faq\/\" class=\"elementor-icon elementor-animation-grow\" tabindex=\"-1\" aria-label=\"FAQS \u2192\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-question\"><\/i>\t\t\t\t<\/a>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/faq\/\" >\n\t\t\t\t\t\t\tFAQS \u2192\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tVragen? Je vindt hier veel antwoorden.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-a50edf7\" data-id=\"a50edf7\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-030ac0c elementor-view-stacked elementor-shape-circle elementor-position-top elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"030ac0c\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/blog\/\" class=\"elementor-icon elementor-animation-grow\" tabindex=\"-1\" aria-label=\"Nieuws en advies \u2192\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"icon icon-comment2\"><\/i>\t\t\t\t<\/a>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/blog\/\" >\n\t\t\t\t\t\t\tNieuws en advies \u2192\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tBezoek onze blog voor actuele informatie.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-25 elementor-top-column elementor-element elementor-element-83bfb64\" data-id=\"83bfb64\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-73c38fe elementor-view-stacked elementor-shape-circle elementor-position-top elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"73c38fe\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/het-protocol-voor-sessies-ons-advies-en-onze-beloften\/\" class=\"elementor-icon elementor-animation-grow\" tabindex=\"-1\" aria-label=\"Wat je kunt verwachten \u2192\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"icon icon-customer-service\"><\/i>\t\t\t\t<\/a>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/www.harmoniceggtherapy.nl\/nl\/het-protocol-voor-sessies-ons-advies-en-onze-beloften\/\" >\n\t\t\t\t\t\t\tWat je kunt verwachten \u2192\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tOns advies &amp; protocol voor sessies &amp; onze beloften\n\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Intake form The Portal to Your Well-Being Harmonise yourself from within using colours, sounds, vibrations, and energy resonance. Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical &amp; Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity &amp; More. Intake Form All new clients are asked [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-4824","page","type-page","status-publish","hentry"],"aioseo_notices":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"trp-custom-language-flag":false},"uagb_author_info":{"display_name":"harmonicegg","author_link":"https:\/\/www.harmoniceggtherapy.nl\/nl\/author\/harmonicegg\/"},"uagb_comment_info":0,"uagb_excerpt":"Intake form The Portal to Your Well-Being Harmonise yourself from within using colours, sounds, vibrations, and energy resonance. Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical &amp; Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity &amp; More. Intake Form All new clients are asked&hellip;","_links":{"self":[{"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/pages\/4824","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/comments?post=4824"}],"version-history":[{"count":0,"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/pages\/4824\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.harmoniceggtherapy.nl\/nl\/wp-json\/wp\/v2\/media?parent=4824"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}