{"id":17,"date":"2024-06-09T14:18:56","date_gmt":"2024-06-09T04:18:56","guid":{"rendered":"https:\/\/forms.thai-remedial.com.au\/?page_id=17"},"modified":"2024-06-10T00:42:58","modified_gmt":"2024-06-09T14:42:58","slug":"client-intake-form","status":"publish","type":"page","link":"https:\/\/beta.forms.thai-remedial.com.au\/core\/client-intake-form\/","title":{"rendered":"Client Intake Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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                          <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/core\/wp-json\/wp\/v2\/pages\/17' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_1_102\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'>LinkedIn<\/label><div class='gfield_description' id='gfield_description_1_102'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_102' id='input_1_102' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><style>\ncanvas#gfds_signature_25 {\n    border: 1px solid #c6c8cb;\n    margin-bottom: 10px;\n}\n\ninput[type=\"button\"], input[type=\"submit\"] {\n    text-transform: none !important;\n    font-weight: 300 !important;\n    font-size: 18px !important;\n    letter-spacing: 1px !important;\n    padding: 8px 18px;\n    margin: 4px;\n    font-family: \"Lato\" !important;\n    max-width: 100%;\n    box-shadow: none !important;\n    transform: none;\n    background: #b18373 !important;\n    color: #fff !important;\n    border-color: rgba(0, 0, 0, 0) !important;\n    line-height: 1.5 !important;\n}\n\ninput[type=\"button\"]:hover, input[type=\"submit\"]:hover {\nbackground: #716864 !important;\n    cursor: pointer;\n}\n\ninput[type=\"submit\"] {\n    background-image: url(\/core\/wp-content\/uploads\/2024\/06\/paper-plane-white.svg) !important;\n    background-repeat: no-repeat !important;\n    background-position: right !important;\n    background-size: 16px !important;\n    background-position-x: 94px !important;\n    padding-right: 38px !important;\n}\n\ninput[type=\"submit\"]:hover {\n    background-image: url(\/core\/wp-content\/uploads\/2024\/06\/paper-plane-white.svg) !important;\n    background-repeat: no-repeat !important;\n    background-position: right !important;\n    background-size: 16px !important;\n    background-position-x: 94px !important;\n    padding-right: 38px !important;\n}\n\n.gform-theme--foundation .gform_footer {\n    justify-content: center;\n}\n.gform_title {\ndisplay:none; }\n\n@media screen and (max-width:639px){\n#body-image {\nwidth: 100%;\n}}\n\n.gform-theme--api, .gform-theme--framework {\n    --gf-font-size-primary:  18px !important;\n    --gf-font-size-secondary: 17px !important;\n    --gf-font-size-tertiary: 18px !important;\n    --gf-ctrl-label-font-size-req: 18px !important;\n    --gf-font-weight-primary: 300 !important;\n    --gf-font-weight-secondary: 400 !important;\n    --gf-font-weight-tertiary: 300 !important;\n    --gf-ctrl-label-font-weight-secondary:  300 !important;\n    --gf-form-footer-margin-y-start: 0px !important;\n    --gf-form-gap-y: 20px;\n}\n\nbody {\n    --wp--preset--font-family--body: \"Lato\", sans-serif;\n    font-weight: 300;\n}\n\n.gform-theme--foundation .gform_page_footer {\n    margin-top: 20px !important;\n    justify-content: center;\n}\n\n.gform-theme--framework .gfield--type-choice .gfield_radio:not(#input_1_72) {\n    flex-direction: row;\n}\n@media screen and (max-width:639px) {\n.gform-theme--framework .gfield--type-choice .gfield_radio#input_1_72 {\n    flex-direction: column;\n}\n}\n\n.gform-theme--framework .gfield--type-choice .gfield_radio#input_1_88 {\n    flex-direction: row;\n    flex-wrap: wrap;\n    justify-content: flex-start;\n    align-content: flex-start;}\n\n.separator {\n    padding: 0 !important;\n    border: 0 !important;\n}\n\n.separator>h3 {\n    display:none !important;\n}\n\nlegend.gfield_label.gform-field-label {\n    display: inline;\n}\n\nspan.gfield_required:not(.gfield_required_asterisk) {\n    margin-left: 5px;\n}\n\n.gform-field-label[for=\"input_1_25\"] {\n    display: none;\n}\n.uppercase>div>input {\ntext-transform:uppercase\n}\n@media screen and (max-width:1279px) {\n#field_1_93, #sig-text {\ndisplay:none;\n}\n}\n\n#field_1_53 {\n    margin-top: -10px;\n}\n\n#gform_wrapper_1[data-form-index=\"0\"].gform-theme {\n--gf-ctrl-label-color-primary: #716864 !important;\n}\n<\/style><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><table width=\"100%\">\n<tbody>\n<tr>\n<td align=\"left\" width=\"50%\"><h1>Client Intake Form<\/h1><\/td>\n<td align=\"right\">\n<p style=\"float:right\">Date: 18\/05\/2026<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Client&#039;s Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'   placeholder='First name' autocomplete=\"given-name\" \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'   placeholder='Last name' autocomplete=\"family-name\" \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_84'>\n\t\t\t<div class='gchoice gchoice_1_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Female'  id='choice_1_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_0' id='label_1_84_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Male'  id='choice_1_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_84_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Rather not say'  id='choice_1_84_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_84_2' id='label_1_84_2' class='gform-field-label gform-field-label--type-inline'>Rather not say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_31\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_31' id='input_1_31' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_31_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_31_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_31' class='gform_hidden' value='https:\/\/beta.forms.thai-remedial.com.au\/core\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_1_17' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_1_18' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_75'>Address (Suburb, Postcode)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_1_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_90\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude separator field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Your health fund provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='AAMI' >AAMI<\/option><option value='ACA Health Benefits Fund' >ACA Health Benefits Fund<\/option><option value='AHM Health Insurance' >AHM Health Insurance<\/option><option value='AIA Health Insurance' >AIA Health Insurance<\/option><option value='Apia Health Insurance' >Apia Health Insurance<\/option><option value='Australian Defence Force Family Health' >Australian Defence Force Family Health<\/option><option value='Australian Unity Health Ltd' >Australian Unity Health Ltd<\/option><option value='Bupa Australia' >Bupa Australia<\/option><option value='CBHS Corporate Health Limited' >CBHS Corporate Health Limited<\/option><option value='CBHS Health Fund Limited' >CBHS Health Fund Limited<\/option><option value='CUA Health Limited' >CUA Health Limited<\/option><option value='Defence Health Limited' >Defence Health Limited<\/option><option value='Doctors\u2019 Health Fund' >Doctors\u2019 Health Fund<\/option><option value='Emergency Services Health' >Emergency Services Health<\/option><option value='Frank Health Insurance' >Frank Health Insurance<\/option><option value='GMHBA Limited' >GMHBA Limited<\/option><option value='Grand United Health' >Grand United Health<\/option><option value='HBF Health Limited' >HBF Health Limited<\/option><option value='HCF Health Care Insurance Ltd' >HCF Health Care Insurance Ltd<\/option><option value='Health Insurance Fund of Australia Ltd (HIF)' >Health Insurance Fund of Australia Ltd (HIF)<\/option><option value='Health Partners' >Health Partners<\/option><option value='Hunter Health Insurance' >Hunter Health Insurance<\/option><option value='La Trobe Health Services' >La Trobe Health Services<\/option><option value='Medibank Private Ltd' >Medibank Private Ltd<\/option><option value='Mildura Health Fund' >Mildura Health Fund<\/option><option value='National Health Benefits Australia Pty Ltd (onemedifund)' >National Health Benefits Australia Pty Ltd (onemedifund)<\/option><option value='Navy Health Limited' >Navy Health Limited<\/option><option value='NIB Health Funds Ltd' >NIB Health Funds Ltd<\/option><option value='Nurses &amp; Midwives Health' >Nurses &amp; Midwives Health<\/option><option value='Peoplecare Health Insurance' >Peoplecare Health Insurance<\/option><option value='Phoenix Health Fund Ltd' >Phoenix Health Fund Ltd<\/option><option value='Police Health' >Police Health<\/option><option value='Qantas Assure Health Insurance' >Qantas Assure Health Insurance<\/option><option value='Queensland Country Health Fund Ltd' >Queensland Country Health Fund Ltd<\/option><option value='Railway and Transport Health Fund Ltd' >Railway and Transport Health Fund Ltd<\/option><option value='Reserve Bank Health Society Limited' >Reserve Bank Health Society Limited<\/option><option value='St.LukesHealth, Suncorp' >St.LukesHealth, Suncorp<\/option><option value='Teachers Health Fund' >Teachers Health Fund<\/option><option value='Transport Health Pty Ltd' >Transport Health Pty Ltd<\/option><option value='TUH' >TUH<\/option><option value='Uni Health' >Uni Health<\/option><option value='Union Health' >Union Health<\/option><option value='Westfund Ltd' >Westfund Ltd<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>&quot;Other&quot; health fund provider name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_101\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude separator field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-post_title gfield--input-type-post_title gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>Member number<\/label><div class='ginput_container ginput_container_post_title'>\n\t\t\t\t\t<input name='input_32' id='input_1_32' type='text' value='' class='large'    aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/div><div id=\"field_1_100\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-half exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/div><fieldset id=\"field_1_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Reason for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_72'>\n\t\t\t<div class='gchoice gchoice_1_72_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Relaxation'  id='choice_1_72_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_0' id='label_1_72_0' class='gform-field-label gform-field-label--type-inline'>Relaxation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_72_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Relieve Stress'  id='choice_1_72_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_1' id='label_1_72_1' class='gform-field-label gform-field-label--type-inline'>Relieve Stress<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_72_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_72' type='radio' value='Specific Problem'  id='choice_1_72_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_72_2' id='label_1_72_2' class='gform-field-label gform-field-label--type-inline'>Specific Problem<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_82\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'>Provide more details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_1_82' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >How much pressure for a massage do you prefer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_78'>\n\t\t\t<div class='gchoice gchoice_1_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Light'  id='choice_1_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Light<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Medium'  id='choice_1_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>Medium<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_78_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Firm'  id='choice_1_78_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_78_2' id='label_1_78_2' class='gform-field-label gform-field-label--type-inline'>Firm<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_95\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-seven-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_95'>Emergency contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_1_95' type='text' value='' class='large'    placeholder='Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-seven-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Emergency contact<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_1_36' type='tel' value='' class='large'  placeholder='Phone number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_97\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude separator field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_98\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude separator field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><strong>Possible areas of soreness<\/strong><img decoding=\"async\" id=\"body-image\" src=\"\/core\/wp-content\/uploads\/2024\/06\/Untitled-design.png\" style=\"\/*margin:0 auto;*\/display:block;max-width: 450px;\"><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Identify specific areas of soreness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_24'>Select area<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Achilles Tendon (back of your calf to your heel bone)'  id='choice_1_24_1'   aria-describedby=\"gfield_description_1_24\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Achilles Tendon (back of your calf to your heel bone)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Ankle Sprains'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>Ankle Sprains<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Arthritic Knees'  id='choice_1_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3' class='gform-field-label gform-field-label--type-inline'>Arthritic Knees<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Arthritic Thumbs'  id='choice_1_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_4' id='label_1_24_4' class='gform-field-label gform-field-label--type-inline'>Arthritic Thumbs<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Back Pain'  id='choice_1_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_5' id='label_1_24_5' class='gform-field-label gform-field-label--type-inline'>Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Bunion Pain (at the base of the big toe)'  id='choice_1_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_6' id='label_1_24_6' class='gform-field-label gform-field-label--type-inline'>Bunion Pain (at the base of the big toe)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.7' type='checkbox'  value='Calf Tears'  id='choice_1_24_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_7' id='label_1_24_7' class='gform-field-label gform-field-label--type-inline'>Calf Tears<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.8' type='checkbox'  value='Carpal Tunnel (wrist)'  id='choice_1_24_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_8' id='label_1_24_8' class='gform-field-label gform-field-label--type-inline'>Carpal Tunnel (wrist)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.9' type='checkbox'  value='Chest Pain'  id='choice_1_24_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_9' id='label_1_24_9' class='gform-field-label gform-field-label--type-inline'>Chest Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.11' type='checkbox'  value='Collapsed Arches (foot)'  id='choice_1_24_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_11' id='label_1_24_11' class='gform-field-label gform-field-label--type-inline'>Collapsed Arches (foot)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.12' type='checkbox'  value='Disc Problems'  id='choice_1_24_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_12' id='label_1_24_12' class='gform-field-label gform-field-label--type-inline'>Disc Problems<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.13' type='checkbox'  value='Frozen Shoulder'  id='choice_1_24_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_13' id='label_1_24_13' class='gform-field-label gform-field-label--type-inline'>Frozen Shoulder<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.14' type='checkbox'  value='Golfers Elbow'  id='choice_1_24_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_14' id='label_1_24_14' class='gform-field-label gform-field-label--type-inline'>Golfers Elbow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.15' type='checkbox'  value='Groin Strain'  id='choice_1_24_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_15' id='label_1_24_15' class='gform-field-label gform-field-label--type-inline'>Groin Strain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.16' type='checkbox'  value='Hamstrings Tears'  id='choice_1_24_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_16' id='label_1_24_16' class='gform-field-label gform-field-label--type-inline'>Hamstrings Tears<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.17' type='checkbox'  value='Headaches'  id='choice_1_24_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_17' id='label_1_24_17' class='gform-field-label gform-field-label--type-inline'>Headaches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.18' type='checkbox'  value='Heel Pain'  id='choice_1_24_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_18' id='label_1_24_18' class='gform-field-label gform-field-label--type-inline'>Heel Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.19' type='checkbox'  value='Hip Pain'  id='choice_1_24_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_19' id='label_1_24_19' class='gform-field-label gform-field-label--type-inline'>Hip Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.21' type='checkbox'  value='Jaw Pain'  id='choice_1_24_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_21' id='label_1_24_21' class='gform-field-label gform-field-label--type-inline'>Jaw Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.22' type='checkbox'  value='Knee Pain'  id='choice_1_24_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_22' id='label_1_24_22' class='gform-field-label gform-field-label--type-inline'>Knee Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.23' type='checkbox'  value='Ligament Tears (thigh &amp; foot)'  id='choice_1_24_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_23' id='label_1_24_23' class='gform-field-label gform-field-label--type-inline'>Ligament Tears (thigh &amp; foot)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.24' type='checkbox'  value='Neck Pain'  id='choice_1_24_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_24' id='label_1_24_24' class='gform-field-label gform-field-label--type-inline'>Neck Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.25' type='checkbox'  value='R.S.I. (forearms)'  id='choice_1_24_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_25' id='label_1_24_25' class='gform-field-label gform-field-label--type-inline'>R.S.I. (forearms)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.26' type='checkbox'  value='Sciatic Pain (back of the leg)'  id='choice_1_24_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_26' id='label_1_24_26' class='gform-field-label gform-field-label--type-inline'>Sciatic Pain (back of the leg)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.27' type='checkbox'  value='Shin Splints'  id='choice_1_24_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_27' id='label_1_24_27' class='gform-field-label gform-field-label--type-inline'>Shin Splints<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.28' type='checkbox'  value='Shoulder Impingement'  id='choice_1_24_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_28' id='label_1_24_28' class='gform-field-label gform-field-label--type-inline'>Shoulder Impingement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.29' type='checkbox'  value='Tennis Elbow'  id='choice_1_24_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_29' id='label_1_24_29' class='gform-field-label gform-field-label--type-inline'>Tennis Elbow<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.31' type='checkbox'  value='Thigh Strain'  id='choice_1_24_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_31' id='label_1_24_31' class='gform-field-label gform-field-label--type-inline'>Thigh Strain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.32' type='checkbox'  value='Upper Back Pain'  id='choice_1_24_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_32' id='label_1_24_32' class='gform-field-label gform-field-label--type-inline'>Upper Back Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.33' type='checkbox'  value='None'  id='choice_1_24_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_33' id='label_1_24_33' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.34' type='checkbox'  value='Other'  id='choice_1_24_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_34' id='label_1_24_34' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Provide more detail &quot;other&quot; areas of soreness<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_88\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Pain scale (10 being the strongest)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_88'>\n\t\t\t<div class='gchoice gchoice_1_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='1'  id='choice_1_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_0' id='label_1_88_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='2'  id='choice_1_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_1' id='label_1_88_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='3'  id='choice_1_88_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_2' id='label_1_88_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='4'  id='choice_1_88_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_3' id='label_1_88_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='5'  id='choice_1_88_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_4' id='label_1_88_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='6'  id='choice_1_88_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_5' id='label_1_88_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='7'  id='choice_1_88_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_6' id='label_1_88_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='8'  id='choice_1_88_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_7' id='label_1_88_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='9'  id='choice_1_88_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_8' id='label_1_88_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_88_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='10'  id='choice_1_88_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_88_9' id='label_1_88_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_61\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>At what time is the pain at its worse?<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_1_61' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Morning' >Morning<\/option><option value='Afternoon' >Afternoon<\/option><option value='Evening' >Evening<\/option><option value='Night' >Night<\/option><option value='During Sleep' >During Sleep<\/option><option value='Pain sometimes' >Pain sometimes<\/option><option value='Always' >Always<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_99\" class=\"gfield gfield--type-section gfield--input-type-section gsection exclude separator field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_1_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever injured this area before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_53'>\n\t\t\t<div class='gchoice gchoice_1_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Yes'  id='choice_1_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_0' id='label_1_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_1_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_53_1' id='label_1_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'>When and how bad was it?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is there anything you do that creates, increases or decreases pain?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_63'>\n\t\t\t<div class='gchoice gchoice_1_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_1_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_1_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List any recent or past injuries illness and medical conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_43'><div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Allergies'  id='choice_1_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Arthritis'  id='choice_1_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Asthma'  id='choice_1_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_3' id='label_1_43_3' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Bleeding Disorders'  id='choice_1_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_4' id='label_1_43_4' class='gform-field-label gform-field-label--type-inline'>Bleeding Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.5' type='checkbox'  value='Blood Clots\/DVT'  id='choice_1_43_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_5' id='label_1_43_5' class='gform-field-label gform-field-label--type-inline'>Blood Clots\/DVT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.6' type='checkbox'  value='Bruising'  id='choice_1_43_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_6' id='label_1_43_6' class='gform-field-label gform-field-label--type-inline'>Bruising<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.7' type='checkbox'  value='Burns'  id='choice_1_43_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_7' id='label_1_43_7' class='gform-field-label gform-field-label--type-inline'>Burns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.8' type='checkbox'  value='Cancer'  id='choice_1_43_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_8' id='label_1_43_8' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.9' type='checkbox'  value='Diabetes'  id='choice_1_43_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_9' id='label_1_43_9' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.11' type='checkbox'  value='Dislocations'  id='choice_1_43_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_11' id='label_1_43_11' class='gform-field-label gform-field-label--type-inline'>Dislocations<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.12' type='checkbox'  value='Epilepsy'  id='choice_1_43_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_12' id='label_1_43_12' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.13' type='checkbox'  value='Fever'  id='choice_1_43_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_13' id='label_1_43_13' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.14' type='checkbox'  value='Fractures'  id='choice_1_43_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_14' id='label_1_43_14' class='gform-field-label gform-field-label--type-inline'>Fractures<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.15' type='checkbox'  value='Harnaids Disc'  id='choice_1_43_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_15' id='label_1_43_15' class='gform-field-label gform-field-label--type-inline'>Harnaids Disc<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.16' type='checkbox'  value='Heart Conditions'  id='choice_1_43_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_16' id='label_1_43_16' class='gform-field-label gform-field-label--type-inline'>Heart Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.17' type='checkbox'  value='Herpes'  id='choice_1_43_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_17' id='label_1_43_17' class='gform-field-label gform-field-label--type-inline'>Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.18' type='checkbox'  value='High Blood Pressure'  id='choice_1_43_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_18' id='label_1_43_18' class='gform-field-label gform-field-label--type-inline'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.19' type='checkbox'  value='Infection'  id='choice_1_43_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_19' id='label_1_43_19' class='gform-field-label gform-field-label--type-inline'>Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.21' type='checkbox'  value='Kidney Aliments'  id='choice_1_43_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_21' id='label_1_43_21' class='gform-field-label gform-field-label--type-inline'>Kidney Aliments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.22' type='checkbox'  value='Lymph Edema'  id='choice_1_43_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_22' id='label_1_43_22' class='gform-field-label gform-field-label--type-inline'>Lymph Edema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.23' type='checkbox'  value='Migraines'  id='choice_1_43_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_23' id='label_1_43_23' class='gform-field-label gform-field-label--type-inline'>Migraines<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.24' type='checkbox'  value='Osteoporosis'  id='choice_1_43_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_24' id='label_1_43_24' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.25' type='checkbox'  value='Phlebitis'  id='choice_1_43_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_25' id='label_1_43_25' class='gform-field-label gform-field-label--type-inline'>Phlebitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.26' type='checkbox'  value='Pregnant'  id='choice_1_43_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_26' id='label_1_43_26' class='gform-field-label gform-field-label--type-inline'>Pregnant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.27' type='checkbox'  value='Psoriasis'  id='choice_1_43_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_27' id='label_1_43_27' class='gform-field-label gform-field-label--type-inline'>Psoriasis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.28' type='checkbox'  value='Recent Surgery'  id='choice_1_43_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_28' id='label_1_43_28' class='gform-field-label gform-field-label--type-inline'>Recent Surgery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.29' type='checkbox'  value='Skin Disease'  id='choice_1_43_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_29' id='label_1_43_29' class='gform-field-label gform-field-label--type-inline'>Skin Disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.31' type='checkbox'  value='Sleep Disorders'  id='choice_1_43_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_31' id='label_1_43_31' class='gform-field-label gform-field-label--type-inline'>Sleep Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.32' type='checkbox'  value='Sprains\/Strains'  id='choice_1_43_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_32' id='label_1_43_32' class='gform-field-label gform-field-label--type-inline'>Sprains\/Strains<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.33' type='checkbox'  value='Stress\/Anxiety'  id='choice_1_43_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_33' id='label_1_43_33' class='gform-field-label gform-field-label--type-inline'>Stress\/Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.34' type='checkbox'  value='Varicose Veins'  id='choice_1_43_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_34' id='label_1_43_34' class='gform-field-label gform-field-label--type-inline'>Varicose Veins<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.35' type='checkbox'  value='Vertigo\/Dizziness'  id='choice_1_43_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_35' id='label_1_43_35' class='gform-field-label gform-field-label--type-inline'>Vertigo\/Dizziness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.36' type='checkbox'  value='None'  id='choice_1_43_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_36' id='label_1_43_36' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.37' type='checkbox'  value='Other'  id='choice_1_43_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_37' id='label_1_43_37' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Other recent or past injuries illness and medical conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever been in an accident? (automobile, work, falls, etc.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_51'>\n\t\t\t<div class='gchoice gchoice_1_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Yes'  id='choice_1_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_51_0' id='label_1_51_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_1_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you ever received therapeutic massage for a specific problem or injury?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_49'>\n\t\t\t<div class='gchoice gchoice_1_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Yes'  id='choice_1_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_1_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently seeing any other healthcare professional?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_55'>\n\t\t\t<div class='gchoice gchoice_1_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_1_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_0' id='label_1_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_1_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_55_1' id='label_1_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_1_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently on medication or any treatments?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_57'>\n\t\t\t<div class='gchoice gchoice_1_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Yes'  id='choice_1_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_0' id='label_1_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_1_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_57_1' id='label_1_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_1_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >History of joint replacement surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_80'>\n\t\t\t<div class='gchoice gchoice_1_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_1_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_80_0' id='label_1_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_1_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_80_1' id='label_1_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_81'>Provide more details<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_1_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_40\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Terms &amp; Conditions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_40.1' id='input_1_40_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_40_1' >I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I\u00a0acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I\u00a0understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I\u00a0understand that at any time I feel pain or discomfort during the session, I\u00a0will immediately inform my therapeutic massage therapist. I\u00a0have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. By my electronic signature below, I agree to the massage policy and client agreement above.<\/label><input type='hidden' name='input_40.2' value='I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. I\u00a0acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I\u00a0understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction. I\u00a0understand that at any time I feel pain or discomfort during the session, I\u00a0will immediately inform my therapeutic massage therapist. I\u00a0have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. By my electronic signature below, I agree to the massage policy and client agreement above.' class='gform_hidden' \/><input type='hidden' name='input_40.3' value='15' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_1_91\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div class=\"gfield gfield--width-full\"><label class=\"gfield_label gform-field-label\">Your Signature<\/label><p id=\"sig-text\" style=\"margin-bottom:0\">Please leave your signature here. 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