{"id":1636,"date":"2023-08-14T10:39:43","date_gmt":"2023-08-14T10:39:43","guid":{"rendered":"https:\/\/starchoicepediatrics.com\/?page_id=1636"},"modified":"2023-08-14T10:40:10","modified_gmt":"2023-08-14T10:40:10","slug":"family-past-medical-form","status":"publish","type":"page","link":"https:\/\/starchoicepediatrics.com\/?page_id=1636","title":{"rendered":"Family &#8211; past medical form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1636\" class=\"elementor elementor-1636\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-f3babd6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"f3babd6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-231a1e0\" data-id=\"231a1e0\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a9f5a7d elementor-widget elementor-widget-shortcode\" data-id=\"a9f5a7d\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1635 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1635\" data-uid=\"69d7317f206a9\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1635\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1635 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1635\"\n\t\t\t\t\n\t\t\t\tdata-design=\"flat\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69d7317f206a9\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1635--page-0\" class=\"forminator-pagination forminator-pagination-start\" aria-labelledby=\"forminator-custom-form-1635--page-0-label\" data-step=\"0\" data-label=\"Finish\" data-name=\"page-break-2\"><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69d7317f206a9\" id=\"forminator-field-name-1_69d7317f206a9-label\" class=\"forminator-label\">Patient name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John\" id=\"forminator-field-name-1_69d7317f206a9\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69d7317f206a9\" id=\"forminator-field-date-1-picker_69d7317f206a9-label\" class=\"forminator-label\">Date of Birth<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-1-picker_69d7317f206a9\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69d7317f206a9\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69d7317f206a9\" id=\"forminator-field-address-1-street_address_69d7317f206a9-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69d7317f206a9\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69d7317f206a9\" id=\"forminator-field-phone-1_69d7317f206a9-label\" class=\"forminator-label\">Phone Number<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 3004005000\" id=\"forminator-field-phone-1_69d7317f206a9\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Section 1 :<\/h2><h3 class=\"forminator-subtitle\">Family History<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_69d7317f206a9\" id=\"forminator-field-textarea-5_69d7317f206a9-label\" class=\"forminator-label\">Mother : ( name ) , ( age ) , (illness)<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >(name : ..........) , ( age : .......... ) , (illness : ...........)<\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_69d7317f206a9\" id=\"forminator-field-textarea-6_69d7317f206a9-label\" class=\"forminator-label\">Father : ( name ) , ( age ) , (illness)<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >(name : ..........) , ( age : .......... ) , (illness : ...........)<\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_69d7317f206a9\" id=\"forminator-field-textarea-7_69d7317f206a9-label\" class=\"forminator-label\">Brothers : ( name ) , ( age ) , (illness)<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >(name : ..........) , ( age : .......... ) , (illness : ...........)<\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8_69d7317f206a9\" id=\"forminator-field-textarea-8_69d7317f206a9-label\" class=\"forminator-label\">Sisters : ( name ) , ( age ) , (illness)<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >(name : ..........) , ( age : .......... ) , (illness : ...........)<\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-9\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9_69d7317f206a9\" id=\"forminator-field-textarea-9_69d7317f206a9-label\" class=\"forminator-label\">Others Relationships : ( name ) , ( age ) , (illness)<\/label><textarea name=\"textarea-9\" placeholder=\"\" id=\"forminator-field-textarea-9_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >(name : ..........) , ( age : .......... ) , (illness : ...........)<\/textarea><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1635--page-1\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1635--page-1-label\" aria-hidden=\"true\" data-step=\"1\" data-label=\"Page  1\" data-name=\"page-break-1\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Section 2 :<\/h2><h3 class=\"forminator-subtitle\">Social History<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Does anyone in current family smoke cigarettes ?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-1-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-1-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69d7317f206a9-label\"><h4 id=\"forminator-checkbox-group-69d7317f206a9-label\" class=\"forminator-label\">Has anyone in child&#039;s biological or natural family (parents, siblings, or grandparents) had:<\/h4><label id=\"forminator-field-checkbox-1-1-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-1-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Bleeding Disorder\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-1-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bleeding Disorder<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-2-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Tuberculosis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-2-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tuberculosis<\/span><\/label><label id=\"forminator-field-checkbox-1-3-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-3-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Asthma\/Allergy (particular to medicines)\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Asthma-Allergy-(particular-to-medicines)\" id=\"forminator-field-checkbox-1-3-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-3-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma\/Allergy (particular to medicines)<\/span><\/label><label id=\"forminator-field-checkbox-1-4-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-4-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Kidney Stones\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Kidney-Stones\" id=\"forminator-field-checkbox-1-4-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-4-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kidney Stones<\/span><\/label><label id=\"forminator-field-checkbox-1-5-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-5-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Heart Attack or Heart Disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Heart-Attack-or-Heart-Disease\" id=\"forminator-field-checkbox-1-5-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-5-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart Attack or Heart Disease<\/span><\/label><label id=\"forminator-field-checkbox-1-6-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-6-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Seizures or Epilepsy\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Seizures-or-Epilepsy\" id=\"forminator-field-checkbox-1-6-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-6-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Seizures or Epilepsy<\/span><\/label><label id=\"forminator-field-checkbox-1-7-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-7-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-1-7-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-7-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-1-8-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-8-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cancer\" id=\"forminator-field-checkbox-1-8-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-8-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><label id=\"forminator-field-checkbox-1-9-69d7317f206a9-label\" for=\"forminator-field-checkbox-1-9-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Anyone in family die before age 40?\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anyone-in-family-die-before-age-40?\" id=\"forminator-field-checkbox-1-9-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-1-9-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anyone in family die before age 40?<\/span><\/label><span id=\"forminator-field-checkbox-1-69d7317f206a9-description\" class=\"forminator-description\">check if yes<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Does anyone other than parent take care of the child regularly?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-2-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-2-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69d7317f206a9\" id=\"forminator-field-text-1_69d7317f206a9-label\" class=\"forminator-label\">Who ?<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Does child attend school (or daycare) regularly?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-3-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-3-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69d7317f206a9\" id=\"forminator-field-text-2_69d7317f206a9-label\" class=\"forminator-label\">Name of school<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69d7317f206a9\" id=\"forminator-field-text-3_69d7317f206a9-label\" class=\"forminator-label\">Grade<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69d7317f206a9\" id=\"forminator-field-text-4_69d7317f206a9-label\" class=\"forminator-label\">Regular Class<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69d7317f206a9\" id=\"forminator-field-text-5_69d7317f206a9-label\" class=\"forminator-label\">Special Class<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Grade Failures<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-4-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-4-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69d7317f206a9\" id=\"forminator-field-text-6_69d7317f206a9-label\" class=\"forminator-label\">Which grade(s):<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69d7317f206a9\" id=\"forminator-field-text-7_69d7317f206a9-label\" class=\"forminator-label\">Home situation: Who shares your home with you and the patient?<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Is this child adopted?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-5-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-5-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div tabindex=\"0\" role=\"tabpanel\" id=\"forminator-custom-form-1635--page-2\" class=\"forminator-pagination\" aria-labelledby=\"forminator-custom-form-1635--page-2-label\" aria-hidden=\"true\" data-step=\"2\" data-label=\"Page  2\" data-name=\"\" hidden><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SECTION 3:<\/h2><h3 class=\"forminator-subtitle\">PAST MEDICAL HISTORY<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69d7317f206a9-label\"><h4 id=\"forminator-checkbox-group-69d7317f206a9-label\" class=\"forminator-label\">During pregnancy with this patient, did patient&#039;s mother experience:<\/h4><label id=\"forminator-field-checkbox-2-1-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-1-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Toxemia or Pre-eclampsia,\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-1-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Toxemia or Pre-eclampsia,<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-2-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Vaginal Bleeding\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-2-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vaginal Bleeding<\/span><\/label><label id=\"forminator-field-checkbox-2-3-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-3-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Alcohol Intake\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Alcohol-Intake\" id=\"forminator-field-checkbox-2-3-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-3-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Alcohol Intake<\/span><\/label><label id=\"forminator-field-checkbox-2-4-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-4-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Smoking\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Smoking\" id=\"forminator-field-checkbox-2-4-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-4-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Smoking<\/span><\/label><label id=\"forminator-field-checkbox-2-5-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-5-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Take any prescriptions\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Take-any-prescriptions\" id=\"forminator-field-checkbox-2-5-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-5-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Take any prescriptions<\/span><\/label><label id=\"forminator-field-checkbox-2-6-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-6-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Take any drugs\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Take-any-drugs\" id=\"forminator-field-checkbox-2-6-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-6-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Take any drugs<\/span><\/label><label id=\"forminator-field-checkbox-2-7-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-7-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Marijuana use\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Marijuana-use\" id=\"forminator-field-checkbox-2-7-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-7-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Marijuana use<\/span><\/label><label id=\"forminator-field-checkbox-2-8-69d7317f206a9-label\" for=\"forminator-field-checkbox-2-8-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Fever\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Fever\" id=\"forminator-field-checkbox-2-8-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-2-8-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-2-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fever<\/span><\/label><span id=\"forminator-field-checkbox-2-69d7317f206a9-description\" class=\"forminator-description\">(Check if Yes)<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">What type of delivery?<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69d7317f206a9\" class=\"forminator-radio\" title=\"vaginal\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-6-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">vaginal<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69d7317f206a9\" class=\"forminator-radio\" title=\"C-section\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-6-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">C-section<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69d7317f206a9\" id=\"forminator-field-text-8_69d7317f206a9-label\" class=\"forminator-label\">What birthweight?<\/label><input type=\"text\" name=\"text-8\" value=\"......... lbs., ..........Oz.\" placeholder=\"\" id=\"forminator-field-text-8_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69d7317f206a9\" id=\"forminator-field-text-9_69d7317f206a9-label\" class=\"forminator-label\">Did delivery occur: at\/before 37 weeks (If Yes, do you know why?<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Were there any complications at birth?<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-7-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-7-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Was the baby yellow in color? (Yellow-Jaundice)<\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-8-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-8-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_69d7317f206a9\" id=\"forminator-field-text-10_69d7317f206a9-label\" class=\"forminator-label\">How many days old was the baby when he\/she went home?<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_69d7317f206a9\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Were there any difficulties after birth?<\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-9-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-9-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Did the baby need oxygen?<\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-10-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-10-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Was the baby blue in color?<\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-11-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-11-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69d7317f206a9-label\" aria-describedby=\"forminator-radiogroup-69d7317f206a9-description\"><span id=\"forminator-radiogroup-69d7317f206a9-label\" class=\"forminator-label\">Has the child ever been hospitalized overnight or had any operations? If yes, please list each admission:<\/span><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-69d7317f206a9\" class=\"forminator-radio\" title=\"yes\"><input type=\"radio\" name=\"radio-12\" value=\"one\" id=\"forminator-field-radio-12-1-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-12-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">yes<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-69d7317f206a9\" class=\"forminator-radio\" title=\"no\"><input type=\"radio\" name=\"radio-12\" value=\"two\" id=\"forminator-field-radio-12-2-69d7317f206a9\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-radio-12-69d7317f206a9-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">no<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69d7317f206a9\" id=\"forminator-field-textarea-2_69d7317f206a9-label\" class=\"forminator-label\">please list each admission:<\/label><textarea name=\"textarea-2\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-2_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" >Hospital, Dates, Reason<\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69d7317f206a9-label\"><h4 id=\"forminator-checkbox-group-69d7317f206a9-label\" class=\"forminator-label\">Did Patient have ?<\/h4><label id=\"forminator-field-checkbox-3-1-69d7317f206a9-label\" for=\"forminator-field-checkbox-3-1-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Asthma\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-3-1-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-3-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69d7317f206a9-label\" for=\"forminator-field-checkbox-3-2-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Hay Fever\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-3-2-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-3-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hay Fever<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69d7317f206a9-label\" for=\"forminator-field-checkbox-3-3-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Food Allergy\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Food-Allergy\" id=\"forminator-field-checkbox-3-3-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-3-3-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-3-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Food Allergy<\/span><\/label><label id=\"forminator-field-checkbox-3-4-69d7317f206a9-label\" for=\"forminator-field-checkbox-3-4-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Penicillin Allergy.\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Penicillin-Allergy.\" id=\"forminator-field-checkbox-3-4-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-3-4-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-3-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Penicillin Allergy.<\/span><\/label><span id=\"forminator-field-checkbox-3-69d7317f206a9-description\" class=\"forminator-description\">(Check if Yes)<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69d7317f206a9-label\"><h4 id=\"forminator-checkbox-group-69d7317f206a9-label\" class=\"forminator-label\">Has patient ever had:<\/h4><label id=\"forminator-field-checkbox-4-1-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-1-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Hepatitis (Yellow Jaundice)\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-1-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hepatitis (Yellow Jaundice)<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-2-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Measles\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-2-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Measles<\/span><\/label><label id=\"forminator-field-checkbox-4-3-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-3-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Chicken Pox\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Chicken-Pox\" id=\"forminator-field-checkbox-4-3-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-3-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Chicken Pox<\/span><\/label><label id=\"forminator-field-checkbox-4-4-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-4-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Ear Infections\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Ear-Infections\" id=\"forminator-field-checkbox-4-4-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-4-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ear Infections<\/span><\/label><label id=\"forminator-field-checkbox-4-5-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-5-69d7317f206a9\" class=\"forminator-checkbox\" title=\"VD\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"VD\" id=\"forminator-field-checkbox-4-5-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-5-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">VD<\/span><\/label><label id=\"forminator-field-checkbox-4-6-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-6-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Bee Sting Allergy\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Bee-Sting-Allergy\" id=\"forminator-field-checkbox-4-6-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-6-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bee Sting Allergy<\/span><\/label><label id=\"forminator-field-checkbox-4-7-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-7-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Any Other Allergy\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Any-Other-Allergy\" id=\"forminator-field-checkbox-4-7-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-7-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Any Other Allergy<\/span><\/label><label id=\"forminator-field-checkbox-4-8-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-8-69d7317f206a9\" class=\"forminator-checkbox\" title=\"Scarlet Fever\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Scarlet-Fever\" id=\"forminator-field-checkbox-4-8-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-8-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Scarlet Fever<\/span><\/label><label id=\"forminator-field-checkbox-4-9-69d7317f206a9-label\" for=\"forminator-field-checkbox-4-9-69d7317f206a9\" class=\"forminator-checkbox\" title=\"German Measles Mumps Strep Throat\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"German-Measles-Mumps-Strep-Throat\" id=\"forminator-field-checkbox-4-9-69d7317f206a9\" aria-labelledby=\"forminator-field-checkbox-4-9-69d7317f206a9-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-69d7317f206a9-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">German Measles Mumps Strep Throat<\/span><\/label><span id=\"forminator-field-checkbox-4-69d7317f206a9-description\" class=\"forminator-description\">(Check if Yes)<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_69d7317f206a9\" id=\"forminator-field-textarea-3_69d7317f206a9-label\" class=\"forminator-label\">List any other serious illness or injuries that the patient has had:<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69d7317f206a9\" id=\"forminator-field-textarea-4_69d7317f206a9-label\" class=\"forminator-label\">List all medications which this child uses regularly or has used regularly in the past:<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69d7317f206a9\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Send Message<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"22b95113ce\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1636\" \/><input type=\"hidden\" name=\"form_id\" value=\"1635\"><input type=\"hidden\" name=\"page_id\" value=\"1636\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/starchoicepediatrics.com\/?page_id=1636\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-1636","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1636","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1636"}],"version-history":[{"count":4,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1636\/revisions"}],"predecessor-version":[{"id":1640,"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=\/wp\/v2\/pages\/1636\/revisions\/1640"}],"wp:attachment":[{"href":"https:\/\/starchoicepediatrics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1636"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}