{"id":20664,"date":"2021-09-14T15:53:43","date_gmt":"2021-09-14T22:53:43","guid":{"rendered":"https:\/\/bariatric-surgery-tijuana.com\/?page_id=20664"},"modified":"2022-01-25T12:13:23","modified_gmt":"2022-01-25T20:13:23","slug":"medical-questionnaire-dr-rodriguez","status":"publish","type":"page","link":"https:\/\/bariatric-surgery-tijuana.com\/medical-questionnaire-dr-rodriguez\/","title":{"rendered":"Medical questionnaire Dr. Rodriguez"},"content":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1601324889419{padding-top: 60px !important;padding-bottom: 60px !important;}&#8221;][vc_column width=&#8221;3\/12&#8243;][\/vc_column][vc_column width=&#8221;6\/12&#8243;][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><strong>All information is confidential. Please answer honestly to assure the best possible procedure for you.<\/strong><\/p>\n<p style=\"text-align: center;\">It is important that all the information provided is true and complete to the best of your knowledge. It is essential the surgeon has complete and accurate information in order to provide safe medical evaluation and care. This medical history is used in providing care through the\u00a0<strong><a href=\"https:\/\/bariatric-surgery-tijuana.com\/\">Bariatric Center<\/a><\/strong>, and some information may need to share with referring physicians\/counselors.<\/p>\n<p>[\/vc_column_text][\/vc_column][vc_column width=&#8221;3\/12&#8243;][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1601415086568{padding-top: 60px !important;padding-bottom: 60px !important;}&#8221; el_class=&#8221;medical-form&#8221;][vc_column width=&#8221;3\/12&#8243;][\/vc_column][vc_column width=&#8221;6\/12&#8243;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f20663-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/20664#wpcf7-f20663-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"20663\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.8.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f20663-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 55\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-name\" class=\"label\">Name<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Name\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 54\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-email\" class=\"label\">Email<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email input-required\" id=\"elm-contact-form-_eabb587e650b558-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Email\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 53\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-phone\" class=\"label\">Phone<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel input-required\" id=\"elm-contact-form-_eabb587e650b558-phone\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Cell Phone Number\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 52\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-age\" class=\"label\">Age<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-age\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Age\" value=\"\" type=\"text\" name=\"age\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<p class=\"input-text full-size  mark-required\" style=\"z-index: 51\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-address\" class=\"label\">Address<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-address\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Address\" value=\"\" type=\"text\" name=\"address\" \/><\/span> <\/span> <\/span>\n<\/p>\n<div class=\"halfrow\">\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 50\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-weight\" class=\"label\">Weight<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"weight\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-weight\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Weight\" value=\"\" type=\"text\" name=\"weight\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 49\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-height\" class=\"label\">Height<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-height\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Height\" value=\"\" type=\"text\" name=\"height\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p>Emergency Contact's\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 47\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-contactname\" class=\"label\">Name<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"contactname\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-contactname\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Emergency Contact&#039;s Name\" value=\"\" type=\"text\" name=\"contactname\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 46\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-contactemail\" class=\"label\">Email<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"contactemail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email input-required\" id=\"elm-contact-form-_eabb587e650b558-contactemail\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Emergency Contact&#039;s Email\" value=\"\" type=\"email\" name=\"contactemail\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 45\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-phonecontact\" class=\"label\">Phone<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"phonecontact\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-phonecontact\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Emergency Contact&#039;s Phone Number\" value=\"\" type=\"text\" name=\"phonecontact\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-text half-size-fl  mark-required\" style=\"z-index: 44\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-relationship\" class=\"label\">Relationship<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"relationship\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required input-required\" id=\"elm-contact-form-_eabb587e650b558-relationship\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relationship With Patient\" value=\"\" type=\"text\" name=\"relationship\" \/><\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<p><label>Procedure Option<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"previuos_surgeries\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"previuos_surgeries\" value=\"Mini Bypass\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Mini Bypass<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"previuos_surgeries\" value=\"Gastric Bypass\" \/><span class=\"wpcf7-list-item-label\">Gastric Bypass<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"previuos_surgeries\" value=\"Gastric Sleeve\" \/><span class=\"wpcf7-list-item-label\">Gastric Sleeve<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"previuos_surgeries\" value=\"Bariatric Revision\" \/><span class=\"wpcf7-list-item-label\">Bariatric Revision<\/span><\/span><\/span><\/span><br \/>\n<label>What is the estimated date you would like to have your operation?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"operation_date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"Select date\" type=\"date\" name=\"operation_date\" \/><\/span><br \/>\n<label>Select surgeon<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"selected-surgeon\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"selected-surgeon\"><option value=\"Dr. Carlos Rodr\u00edguez\">Dr. Carlos Rodr\u00edguez<\/option><\/select><\/span><br \/>\n<label>Have you had any previous surgeries?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"previous_surgery\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"previous_surgery\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"previous_surgery\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n<label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"previous_surgery_description\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Tell us about those previous experiences.  Don\u2019t be shy \u2013 dive right in and go into detail.\" name=\"previous_surgery_description\"><\/textarea><\/span><\/label>\n<\/p>\n<div class=\"halfrow\">\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 35\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Respiratory Conditions<\/strong> <\/span> <\/span> <span class=\"input-wrap\"> <span><br \/>\n<label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Asthma\/wheezing\" \/><span class=\"wpcf7-list-item-label\">Asthma\/wheezing<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Emphysema\" \/><span class=\"wpcf7-list-item-label\">Emphysema<\/span><\/span><\/span><\/span> <\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Pneumonia\/Bronchitis\" \/><span class=\"wpcf7-list-item-label\">Pneumonia\/Bronchitis<\/span><\/span><\/span><\/span><\/label><\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Cannot breath lying flat\" \/><span class=\"wpcf7-list-item-label\">Cannot breath lying flat<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Shortness of breath\" \/><span class=\"wpcf7-list-item-label\">Shortness of breath<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-6\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Frequent coughs\/colds\" \/><span class=\"wpcf7-list-item-label\">Frequent coughs\/colds<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-7\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Coughing up blood\/mucus\" \/><span class=\"wpcf7-list-item-label\">Coughing up blood\/mucus<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-8\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Soaking night sweats\" \/><span class=\"wpcf7-list-item-label\">Soaking night sweats<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-9\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-10\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"Sleep APNEA\" \/><span class=\"wpcf7-list-item-label\">Sleep APNEA<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"respiratory\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-respiratory-11\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"respiratory[]\" value=\"I use a CPAP Machine\" \/><span class=\"wpcf7-list-item-label\">I use a CPAP Machine<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span><br \/>\n<\/span>\n\t<\/p>\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 34\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Cardiovascular Conditions<\/strong><\/span> <\/span> <span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Heart valve problems\" \/><span class=\"wpcf7-list-item-label\">Heart valve problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Chest pain\" \/><span class=\"wpcf7-list-item-label\">Chest pain<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Heart attack\" \/><span class=\"wpcf7-list-item-label\">Heart attack<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"High blood pressure\" \/><span class=\"wpcf7-list-item-label\">High blood pressure<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"High cholesterol\" \/><span class=\"wpcf7-list-item-label\">High cholesterol<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-6\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Varicose veins\" \/><span class=\"wpcf7-list-item-label\">Varicose veins<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-7\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Edema\/Swelling\" \/><span class=\"wpcf7-list-item-label\">Edema\/Swelling<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-8\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Pacemaker\" \/><span class=\"wpcf7-list-item-label\">Pacemaker<\/span><\/span><\/span><\/span> <\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cardiovascular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-cardiovascular-9\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"cardiovascular[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 33\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Gastrointestinal Conditions<\/strong><\/span> <\/span><br \/>\n<span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Ulcers\" \/><span class=\"wpcf7-list-item-label\">Ulcers<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Liver or Gallbladder problems\" \/><span class=\"wpcf7-list-item-label\">Liver or Gallbladder problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Bowel irregularities\" \/><span class=\"wpcf7-list-item-label\">Bowel irregularities<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Abdominal pain\" \/><span class=\"wpcf7-list-item-label\">Abdominal pain<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-6\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Acid reflux\" \/><span class=\"wpcf7-list-item-label\">Acid reflux<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"gastrointestinal\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-gastrointestinal-7\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"gastrointestinal[]\" value=\"Heartburn\" \/><span class=\"wpcf7-list-item-label\">Heartburn<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span><br \/>\n<\/span>\n\t<\/p>\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 32\"><br \/>\n<span class=\"input-row\"><br \/>\n<span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Urinary Conditions<\/strong><\/span> <\/span><br \/>\n<span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"urinary\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-urinary-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"urinary[]\" value=\"Kidney stones\" \/><span class=\"wpcf7-list-item-label\">Kidney stones<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"urinary\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-urinary-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"urinary[]\" value=\"Frequent urination\" \/><span class=\"wpcf7-list-item-label\">Frequent urination<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"urinary\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-urinary-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"urinary[]\" value=\"Bladder control problems\" \/><span class=\"wpcf7-list-item-label\">Bladder control problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"urinary\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-urinary-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"urinary[]\" value=\"Painful urination\" \/><span class=\"wpcf7-list-item-label\">Painful urination<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"urinary\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-urinary-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"urinary[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span><br \/>\n<\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 31\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Muscular Conditions<\/strong><\/span> <\/span> <span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"muscular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-muscular-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"muscular[]\" value=\"Bone\/joint problems\" \/><span class=\"wpcf7-list-item-label\">Bone\/joint problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"muscular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-muscular-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"muscular[]\" value=\"Back\/neck pain\" \/><span class=\"wpcf7-list-item-label\">Back\/neck pain<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"muscular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-muscular-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"muscular[]\" value=\"Arthritis\/gout\" \/><span class=\"wpcf7-list-item-label\">Arthritis\/gout<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"muscular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-muscular-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"muscular[]\" value=\"Knee\/Hip surgery\" \/><span class=\"wpcf7-list-item-label\">Knee\/Hip surgery<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"muscular\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-muscular-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"muscular[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 30\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Neuro Conditions<\/strong><\/span> <\/span> <span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"neuro\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-neuro-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"neuro[]\" value=\"Dizziness\" \/><span class=\"wpcf7-list-item-label\">Dizziness<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"neuro\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-neuro-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"neuro[]\" value=\"Sleep Apnea\" \/><span class=\"wpcf7-list-item-label\">Sleep Apnea<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"neuro\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-neuro-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"neuro[]\" value=\"Stroke\" \/><span class=\"wpcf7-list-item-label\">Stroke<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"neuro\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-neuro-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"neuro[]\" value=\"Seizures\" \/><span class=\"wpcf7-list-item-label\">Seizures<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"neuro\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-neuro-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"neuro[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<div class=\"halfrow\">\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 29\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Endocrine Conditions<\/strong><\/span> <\/span> <span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"endocrine\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-endocrine-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"endocrine[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"endocrine\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-endocrine-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"endocrine[]\" value=\"Thyroid Problems\" \/><span class=\"wpcf7-list-item-label\">Thyroid Problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"endocrine\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-endocrine-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"endocrine[]\" value=\"Tiredness\/Fatigue\" \/><span class=\"wpcf7-list-item-label\">Tiredness\/Fatigue<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"endocrine\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-endocrine-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"endocrine[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n\t<\/p>\n\t<p class=\"input-chbox-vertical half-size-fl  mark-required\" style=\"z-index: 28\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Emotional Conditions<\/strong><\/span> <\/span><br \/>\n<span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"emotional\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-emotional-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"emotional[]\" value=\"Depression or emotional problems\" \/><span class=\"wpcf7-list-item-label\">Depression or emotional problems<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"emotional\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-emotional-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"emotional[]\" value=\"Anxiety\/Stress\" \/><span class=\"wpcf7-list-item-label\">Anxiety\/Stress<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"emotional\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-emotional-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"emotional[]\" value=\"Mood disorders\" \/><span class=\"wpcf7-list-item-label\">Mood disorders<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"emotional\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-emotional-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"emotional[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n\t<\/p>\n<\/div>\n<p class=\"input-textarea full-size nolabel \" style=\"z-index: 27\"><br \/>\n<span class=\"input-row\"> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"medical\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"elm-contact-form-_eabb587e650b558-medical\" aria-invalid=\"false\" placeholder=\"Tell us about any other medical diseases and conditions you suffer, or have suffered.  Don\u2019t be shy \u2013 dive right in and go into detail.\" name=\"medical\"><\/textarea><\/span> <\/span> <\/span>\n<\/p>\n<p class=\"input-text full-size  \" style=\"z-index: 26\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <label for=\"elm-contact-form-_eabb587e650b558-supplements\" class=\"label\">Supplements<\/label> <\/span> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"supplements\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"elm-contact-form-_eabb587e650b558-supplements\" aria-invalid=\"false\" placeholder=\"Please list all vitamins and supplements you take, even if not taken every day.\" value=\"\" type=\"text\" name=\"supplements\" \/><\/span> <\/span> <\/span>\n<\/p>\n<p class=\"input-chbox-vertical full-size  mark-required\" style=\"z-index: 25\"><br \/>\n<span class=\"input-row\"> <span class=\"input-label\"> <span class=\"label\"><strong style=\"display:inline-block;margin-top:15px;text-transform: uppercase;font-size:18px;color: #000;\">Have you ever...<\/strong><\/span> <\/span> <span class=\"input-wrap\"><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-1\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Smoked cigarettes or cigars\" \/><span class=\"wpcf7-list-item-label\">Smoked cigarettes or cigars<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-2\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Vaped or used E-cigs\" \/><span class=\"wpcf7-list-item-label\">Vaped or used E-cigs<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-3\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Chewed Tobacco\" \/><span class=\"wpcf7-list-item-label\">Chewed Tobacco<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-4\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Are you a frequent smoker?\" \/><span class=\"wpcf7-list-item-label\">Are you a frequent smoker?<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-5\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Drank Energy Drinks\" \/><span class=\"wpcf7-list-item-label\">Drank Energy Drinks<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-6\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Used caffeine tablets\" \/><span class=\"wpcf7-list-item-label\">Used caffeine tablets<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-7\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Drank coffee\" \/><span class=\"wpcf7-list-item-label\">Drank coffee<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-8\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Drank tea\" \/><span class=\"wpcf7-list-item-label\">Drank tea<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-9\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Drank sodas\" \/><span class=\"wpcf7-list-item-label\">Drank sodas<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-10\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Drank alcohol\" \/><span class=\"wpcf7-list-item-label\">Drank alcohol<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-11\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Exercised for health or weight loss\" \/><span class=\"wpcf7-list-item-label\">Exercised for health or weight loss<\/span><\/span><\/span><\/span><\/label> <\/span><br \/>\n<span> <label> <span class=\"wpcf7-form-control-wrap\" data-name=\"ever\"><span class=\"wpcf7-form-control wpcf7-checkbox input-required\" id=\"elm-contact-form-_eabb587e650b558-ever-12\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"ever[]\" value=\"Not applicable\" \/><span class=\"wpcf7-list-item-label\">Not applicable<\/span><\/span><\/span><\/span><\/label> <\/span> <\/span> <\/span>\n<\/p>\n<p class=\"input-textarea full-size nolabel \" style=\"z-index: 24\"><br \/>\n<span class=\"input-row\"> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"elaborate\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"elm-contact-form-_eabb587e650b558-elaborate\" aria-invalid=\"false\" placeholder=\"Please elaborate, if one or more of the above options apply to you...\" name=\"elaborate\"><\/textarea><\/span> <\/span> <\/span>\n<\/p>\n<p><label>Have you had or do you currently have any infectious diseases such as VIH \/ HEPATITIS etc..<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"infectious_diseases\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"infectious_diseases\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"infectious_diseases\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p class=\"input-textarea full-size nolabel \" style=\"z-index: 21\"><br \/>\n<span class=\"input-row\"> <span class=\"input-wrap\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"elaborate_infectious_diseases\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"elm-contact-form-_eabb587e650b558-elaborate_infectious_diseases\" aria-invalid=\"false\" placeholder=\"Please elaborate, if apply to you...\" name=\"elaborate_infectious_diseases\"><\/textarea><\/span> <\/span> <\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"inv-recaptcha-holder\"><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][vc_column width=&#8221;3\/12&#8243;][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1492593472409{background-color: #43d5cb !important;}&#8221;][vc_column]<div class=\"mkdf-call-to-action-holder  mkdf-normal-layout no-proportion\">\n\t<div class=\"mkdf-cta-inner \">\n\t\t<div class=\"mkdf-cta-text-holder\">\n\t\t\t<div class=\"mkdf-cta-text\">\n<h4><span style=\"color: #ffffff; font-size: 36px; line-height: 40px; font-family: 'BenchNine', sans-serif;\">CONTACT US VIA WHATSAPP TO GET MORE INFORMATION ABOUT OUR SERVICES<\/span><\/h4>\n<\/div>\n\t\t<\/div>\n\t\t<div class=\"mkdf-cta-button-holder\" >\n\t\t\t\t\t\t<div class=\"mkdf-cta-button\"><a itemprop=\"url\" href=\"https:\/\/api.whatsapp.com\/send?phone=16197794368&#038;text=\" target=\"_self\" class=\"mkdf-btn mkdf-btn-medium mkdf-btn-solid mkdf-btn-solid-light mkdf-btn-icon\" rel=\"noopener\">    <span class=\"mkdf-btn-text\">Go to Whatsapp<\/span>    <span class=\"mkdf-btn-icon-holder\">        <span class=\"mkdf-btn-icon-normal\" ><i class=\"mkdf-icon-ion-icon ion-chevron-right \" ><\/i><\/span>        <span class=\"mkdf-btn-icon-flip\" ><i class=\"mkdf-icon-ion-icon ion-chevron-right \" ><\/i><\/span>    <\/span><\/a><\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>[\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1601324889419{padding-top: 60px !important;padding-bottom: 60px !important;}&#8221;][vc_column width=&#8221;3\/12&#8243;][\/vc_column][vc_column width=&#8221;6\/12&#8243;][vc_column_text] All information is confidential. Please answer honestly to assure the best possible procedure for you. It is important that all the information provided is true and complete to the best of your [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"full-width.php","meta":{"footnotes":"","_joinchat":[]},"_links":{"self":[{"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/pages\/20664"}],"collection":[{"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/comments?post=20664"}],"version-history":[{"count":2,"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/pages\/20664\/revisions"}],"predecessor-version":[{"id":21116,"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/pages\/20664\/revisions\/21116"}],"wp:attachment":[{"href":"https:\/\/bariatric-surgery-tijuana.com\/wp-json\/wp\/v2\/media?parent=20664"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}