{"id":687,"date":"2023-02-06T03:50:51","date_gmt":"2023-02-06T08:50:51","guid":{"rendered":"https:\/\/forms.blossomhc.net\/?page_id=687"},"modified":"2023-02-21T11:16:23","modified_gmt":"2023-02-21T16:16:23","slug":"annual-health-assessment","status":"publish","type":"page","link":"https:\/\/forms.blossomhc.net\/annual-health-assessment\/","title":{"rendered":"Annual Health Assessment"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Annual Health Assessment<\/h2>\n                            <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='\/wp-json\/wp\/v2\/pages\/687' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_50\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>Employee 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_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>Last 4 of SS#<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>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_7' id='input_1_7' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><label class='gfield_label gform-field-label' for='input_1_51'>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_51' id='input_1_51' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_5\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_1_5_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_1_5_1' id='input_1_5_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_1_5_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_1_5_2' id='input_1_5_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_1_5_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_1_5_3' id='input_1_5_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_1_5_4' value=''     placeholder='State' aria-required='true'    \/>\n                                        <label for='input_1_5_4' id='input_1_5_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_1_5_5' value=''   placeholder='Zip' aria-required='true'    \/>\n                                    <label for='input_1_5_5' id='input_1_5_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_1_5_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_13\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" >Have you had or do you have any of the following conditions\/symptoms?<\/div><fieldset id=\"field_1_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies<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_35'><div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Yes'  id='choice_1_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='No'  id='choice_1_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_2' id='label_1_35_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arthritis<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_40'><div class='gchoice gchoice_1_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Yes'  id='choice_1_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_40_1' id='label_1_40_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='No'  id='choice_1_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_40_2' id='label_1_40_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Seizures<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_47'><div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Yes'  id='choice_1_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='No'  id='choice_1_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Diabetes<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_42'><div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Yes'  id='choice_1_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='No'  id='choice_1_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_2' id='label_1_42_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Heart Trouble<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='Yes'  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'>Yes<\/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='No'  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'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Exposure to Hepatitis<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_44'><div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Yes'  id='choice_1_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='No'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >High Blood Pressure<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_45'><div class='gchoice gchoice_1_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Yes'  id='choice_1_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='No'  id='choice_1_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Surgery within Past Year<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_46'><div class='gchoice gchoice_1_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Yes'  id='choice_1_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='No'  id='choice_1_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third hidecheckbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Back Trouble<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_41'><div class='gchoice gchoice_1_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Yes'  id='choice_1_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_41_1' id='label_1_41_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='No'  id='choice_1_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_41_2' id='label_1_41_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><legend class='gfield_label gform-field-label' >Have you had ANY immunizations, such as flu or tetanus shots, in the past year?<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_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_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_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>Please enter the date and type of immunization<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" >Name of a physician you would like us to contact in the event of any emergency or illness:<\/div><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><label class='gfield_label gform-field-label' for='input_1_24'>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_24' id='input_1_24' type='text' value='' class='large'    placeholder='Name of Physician' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'    placeholder='Phone # of Physician' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\" ><legend class='gfield_label gform-field-label' >Do you have any health impairment which is of potential risk to the patient, or which might interfere with the performance of your duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol, \u00bfor other drugs which may alter your behavior?<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_27'>\n\t\t\t<div class='gchoice gchoice_1_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Yes'  id='choice_1_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_0' id='label_1_27_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_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='No'  id='choice_1_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_27_1' id='label_1_27_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_28\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><label class='gfield_label gform-field-label' for='input_1_28'>Please explain the impairment<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_1_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>What is your current weight?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_29' id='input_1_29' type='number' step='any'   value='' class='large'    placeholder='Enter a numerical value in lbs.' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>What is your current height?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_31' id='input_1_31' type='number' step='any'   value='' class='large'    placeholder='Enter a numerical value in inches.' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><legend class='gfield_label gform-field-label' >Are you currently taking medication prescribed by a physician?<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_32'>\n\t\t\t<div class='gchoice gchoice_1_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Yes'  id='choice_1_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_32_0' id='label_1_32_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_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='No'  id='choice_1_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_32_1' id='label_1_32_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><label class='gfield_label gform-field-label' for='input_1_33'>What medication and for what reason<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Certification<\/legend><div class='ginput_container ginput_container_consent'><input name='input_34.1' id='input_1_34_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_34_1' >I certify that the information I have provided on this health assessment is true to the best of my knowledge. I understand that this assessment is not for diagnosis or treatment purposes, nor does it replace my physician\u2019s medical examination.<\/label><input type='hidden' name='input_34.2' value='I certify that the information I have provided on this health assessment is true to the best of my knowledge. 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