{"id":1084,"date":"2023-11-23T11:09:13","date_gmt":"2023-11-23T11:09:13","guid":{"rendered":"https:\/\/www.ottawaperiodontist.com\/health-questionnaire\/"},"modified":"2025-09-08T12:40:55","modified_gmt":"2025-09-08T12:40:55","slug":"questionnaire-de-sante","status":"publish","type":"page","link":"https:\/\/www.ottawaperiodontist.com\/fr\/questionnaire-de-sante\/","title":{"rendered":"Questionnaire de sant\u00e9"},"content":{"rendered":"[vc_row type=\u00a0\u00bbfull_width_background\u00a0\u00bb full_screen_row_position=\u00a0\u00bbmiddle\u00a0\u00bb column_margin=\u00a0\u00bbdefault\u00a0\u00bb column_direction=\u00a0\u00bbdefault\u00a0\u00bb column_direction_tablet=\u00a0\u00bbdefault\u00a0\u00bb column_direction_phone=\u00a0\u00bbdefault\u00a0\u00bb bg_color=\u00a0\u00bb#333333&Prime; bg_image=\u00a0\u00bb1132&Prime; bg_position=\u00a0\u00bbright center\u00a0\u00bb background_image_loading=\u00a0\u00bbdefault\u00a0\u00bb bg_repeat=\u00a0\u00bbno-repeat\u00a0\u00bb 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_10' style='display:none'><style>#gform_wrapper_10[data-form-index=\"0\"].gform-theme,[data-parent-form=\"10_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/fr\/wp-json\/wp\/v2\/pages\/1084' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_10_234\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_234'>Facebook<\/label><div class='ginput_container'><input name='input_234' id='input_10_234' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_10_234'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_10_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection full-title field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Les informations suivantes sont confidentielles et destin\u00e9es \u00e0 nos dossiers uniquement.<\/h3><\/div><div id=\"field_10_207\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_207'>Salutation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_207' id='input_10_207' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='M.' >M.<\/option><option value='Mme.' >Mme.<\/option><option value='Mlle.' >Mlle.<\/option><option value='Dr.' >Dr.<\/option><option value='Mx.' >Mx.<\/option><\/select><\/div><\/div><div id=\"field_10_178\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_178'>Nom complet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_178' id='input_10_178' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_128\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_128'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_128' id='input_10_128' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_128_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_128_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_128' class='gform_hidden' value='https:\/\/www.ottawaperiodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_68'>Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_10_68' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_70'>Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_10_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_71'>Code Postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_10_71' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_182\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_182'>T\u00e9l\u00e9phone domicile #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_182' id='input_10_182' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_183\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_183'>Cellulaire #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_183' id='input_10_183' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_208\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_208'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_10_208' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_129\" class=\"gfield gfield--type-html gfield--input-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\"  >En cas d'urgence, nous devrions notifier <\/div><div id=\"field_10_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_78'>Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_10_78' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_184\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_184'>T\u00e9l\u00e9phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_184' id='input_10_184' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_130\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_130'>Relation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_10_130' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_196\" class=\"gfield gfield--type-html gfield--input-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\"  >Informations du tuteur (si applicable) <\/div><div id=\"field_10_197\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_197'>Nom<\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_10_197' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_198\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_198'>Relation<\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_10_198' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_199\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_199'>T\u00e9l\u00e9phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_199' id='input_10_199' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_209\" class=\"gfield gfield--type-html gfield--input-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\"  >Informations m\u00e9dicales<\/div><div id=\"field_10_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_83'>M\u00e9decin de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_10_83' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_185\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_185'>T\u00e9l\u00e9phone du m\u00e9decin de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_185' id='input_10_185' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_132'>Sp\u00e9cialiste m\u00e9dical<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_10_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_133'>Domaine de sp\u00e9cialit\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_10_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_186\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_186'>T\u00e9l\u00e9phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_186' id='input_10_186' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_136'>Autre m\u00e9decin sp\u00e9cialiste<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_10_136' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_137'>Domaine de sp\u00e9cialit\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_10_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_187\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_187'>T\u00e9l\u00e9phone #<\/label><div class='ginput_container ginput_container_phone'><input name='input_187' id='input_10_187' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_80'>Qui vous a r\u00e9f\u00e9r\u00e9 \u00e0 notre cabinet ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_10_80' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_210\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_210'>Veuillez indiquer votre num\u00e9ro de carte sant\u00e9 (OHIP)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_10_210' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_135\" class=\"gfield gfield--type-html gfield--input-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\"  >Les informations suivantes sont n\u00e9cessaires pour nous permettre de vous offrir les meilleurs soins dentaires possibles. Toutes les informations sont strictement priv\u00e9es et prot\u00e9g\u00e9es par la confidentialit\u00e9 m\u00e9decin-patient. Le dentiste examinera les questions et expliquera celles que vous ne comprenez pas.<\/div><div id=\"field_10_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_140'>1. Avez-vous des douleurs\u00a0? O\u00f9?<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_10_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_141'>Gencives qui saignent\u00a0? O\u00f9?<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_10_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_142'>Implants dentaires ? Date de pose ?<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_10_142' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_144\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >2. Avez-vous d\u00e9j\u00e0 subi un traumatisme \u00e0 la m\u00e2choire, \u00e0 la bouche et\/ou aux dents ?<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_10_144'><div class='gchoice gchoice_10_144_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.1' type='checkbox'  value='Oui'  id='choice_10_144_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_144_1' id='label_10_144_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_144_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_144.2' type='checkbox'  value='No'  id='choice_10_144_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_144_2' id='label_10_144_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_145\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_145'>Si oui, o\u00f9 ?<\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_10_145' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_146'>3. Quand avez-vous fait votre dernier examen m\u00e9dical complet avec prise de sang ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_10_146' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_147\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >4. Un m\u00e9decin ou chirurgien vous a-t-il d\u00e9j\u00e0 recommand\u00e9 une pr\u00e9m\u00e9dication avant tout traitement dentaire ?<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_10_147'><div class='gchoice gchoice_10_147_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.1' type='checkbox'  value='Oui'  id='choice_10_147_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_147_1' id='label_10_147_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_147_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_147.2' type='checkbox'  value='No'  id='choice_10_147_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_147_2' id='label_10_147_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_148\" class=\"gfield gfield--type-html gfield--input-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\"  >5. Avez-vous ou avez-vous eu l\u2019une des conditions suivantes<\/div><fieldset id=\"field_10_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Apn\u00e9e du sommeil<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_10_16'><div class='gchoice gchoice_10_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Oui'  id='choice_10_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_16_1' id='label_10_16_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='No'  id='choice_10_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_16_2' id='label_10_16_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_211\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_211'>Si oui, portez-vous une machine? Quel type<\/label><div class='ginput_container ginput_container_text'><input name='input_211' id='input_10_211' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_179\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Diab\u00e8te<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_10_179'><div class='gchoice gchoice_10_179_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.1' type='checkbox'  value='Tapez I'  id='choice_10_179_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_179_1' id='label_10_179_1' class='gform-field-label gform-field-label--type-inline'>Tapez I<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_179_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.2' type='checkbox'  value='Tapez II'  id='choice_10_179_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_179_2' id='label_10_179_2' class='gform-field-label gform-field-label--type-inline'>Tapez II<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_179_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.3' type='checkbox'  value='Non'  id='choice_10_179_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_179_3' id='label_10_179_3' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_212\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_212'>Quel est votre HbA1C ?<\/label><div class='ginput_container ginput_container_text'><input name='input_212' id='input_10_212' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Maladie thyro\u00efdienne<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_10_17'><div class='gchoice gchoice_10_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Oui'  id='choice_10_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_1' id='label_10_17_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='No'  id='choice_10_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_2' id='label_10_17_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_98'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_10_98' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Asthme, MPOC, emphys\u00e8me<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_10_18'><div class='gchoice gchoice_10_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Oui'  id='choice_10_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_1' id='label_10_18_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_18_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.2' type='checkbox'  value='No'  id='choice_10_18_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_18_2' id='label_10_18_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_99'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_10_99' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_20\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Hypertension art\u00e9rielle<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_10_20'><div class='gchoice gchoice_10_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='Oui'  id='choice_10_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_20_1' id='label_10_20_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='No'  id='choice_10_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_20_2' id='label_10_20_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_100'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_10_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Crise cardiaque<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_10_21'><div class='gchoice gchoice_10_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Oui'  id='choice_10_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_21_1' id='label_10_21_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='No'  id='choice_10_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_21_2' id='label_10_21_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_101\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_101'>Quand?<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_10_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Stimulateur cardiaque, stent<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_10_22'><div class='gchoice gchoice_10_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Oui'  id='choice_10_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_22_1' id='label_10_22_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='No'  id='choice_10_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_22_2' id='label_10_22_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_102\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_102'>Quand?<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_10_102' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_23\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Douleur thoracique\/angine<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_10_23'><div class='gchoice gchoice_10_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='Oui'  id='choice_10_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_1' id='label_10_23_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='No'  id='choice_10_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_23_2' id='label_10_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_103'>Quand?<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_10_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_213\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >AVC<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_10_213'><div class='gchoice gchoice_10_213_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.1' type='checkbox'  value='Oui'  id='choice_10_213_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_213_1' id='label_10_213_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_213_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_213.2' type='checkbox'  value='No'  id='choice_10_213_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_213_2' id='label_10_213_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_214\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_214'>Quand?<\/label><div class='ginput_container ginput_container_text'><input name='input_214' id='input_10_214' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arthrite (rhumato\u00efde ou ost\u00e9o)<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_10_24'><div class='gchoice gchoice_10_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Oui'  id='choice_10_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_24_1' id='label_10_24_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='No'  id='choice_10_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_24_2' id='label_10_24_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_104\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_104'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_10_104' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_232\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00c9pisodes vasovagaux \/ \u00e9vanouissements<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_10_232'><div class='gchoice gchoice_10_232_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_232.1' type='checkbox'  value='Oui'  id='choice_10_232_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_232_1' id='label_10_232_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_232_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_232.2' type='checkbox'  value='No'  id='choice_10_232_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_232_2' id='label_10_232_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_233\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_233'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_10_233' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >\u00c9pilepsie<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_10_25'><div class='gchoice gchoice_10_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Oui'  id='choice_10_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_1' id='label_10_25_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='No'  id='choice_10_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_25_2' id='label_10_25_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_105'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_10_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Maladie r\u00e9nale<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_10_27'><div class='gchoice gchoice_10_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Oui'  id='choice_10_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_1' id='label_10_27_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='No'  id='choice_10_27_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_2' id='label_10_27_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_106\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_106'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_10_106' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_31\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reflux acide<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_10_31'><div class='gchoice gchoice_10_31_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.1' type='checkbox'  value='Oui'  id='choice_10_31_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_31_1' id='label_10_31_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_31_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_31.2' type='checkbox'  value='No'  id='choice_10_31_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_31_2' id='label_10_31_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_107'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_10_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Anxi\u00e9t\u00e9\/D\u00e9pression<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_10_32'><div class='gchoice gchoice_10_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Oui'  id='choice_10_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_32_1' id='label_10_32_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='No'  id='choice_10_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_32_2' id='label_10_32_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_108\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_108'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_10_108' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ost\u00e9oporose  (Trait\u00e9\/non-trait\u00e9)<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_10_33'><div class='gchoice gchoice_10_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Oui'  id='choice_10_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_33_1' id='label_10_33_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='No'  id='choice_10_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_33_2' id='label_10_33_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_109\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_109'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_10_109' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Probl\u00e8mes de saignement<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_10_34'><div class='gchoice gchoice_10_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Oui'  id='choice_10_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_34_1' id='label_10_34_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='No'  id='choice_10_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_34_2' id='label_10_34_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_110'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_10_110' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_150\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Probl\u00e8mes de foie<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_10_150'><div class='gchoice gchoice_10_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='Oui'  id='choice_10_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_150_1' id='label_10_150_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='No'  id='choice_10_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_150_2' id='label_10_150_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_149\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_149'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_10_149' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_151\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D\u00e9pendance aux drogues\/alcool<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_10_151'><div class='gchoice gchoice_10_151_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.1' type='checkbox'  value='Oui'  id='choice_10_151_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_151_1' id='label_10_151_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_151_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_151.2' type='checkbox'  value='No'  id='choice_10_151_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_151_2' id='label_10_151_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half explain_fild field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_152'>S&#039;il vous pla\u00eet, expliquez<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_10_152' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_153\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer<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_10_153'><div class='gchoice gchoice_10_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Oui'  id='choice_10_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_1' id='label_10_153_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_153_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.2' type='checkbox'  value='No'  id='choice_10_153_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_153_2' id='label_10_153_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_189\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_189'>Quand?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_189' id='input_10_189' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_189_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_189_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_189' class='gform_hidden' value='https:\/\/www.ottawaperiodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_215\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chimioth\u00e9rapie<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_10_215'><div class='gchoice gchoice_10_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Oui'  id='choice_10_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_215_1' id='label_10_215_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='No'  id='choice_10_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_215_2' id='label_10_215_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_217\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_217'>Quand?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_217' id='input_10_217' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_217_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_217_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_217' class='gform_hidden' value='https:\/\/www.ottawaperiodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_10_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Radiation<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_10_41'><div class='gchoice gchoice_10_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Oui'  id='choice_10_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_41_1' id='label_10_41_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_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_10_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_41_2' id='label_10_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><div id=\"field_10_188\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_188'>Quand?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_188' id='input_10_188' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_188_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_10_188_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_188' class='gform_hidden' value='https:\/\/www.ottawaperiodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_155'>Articulation artificielle ou proth\u00e9tique (date de la chirurgie ?)<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_10_155' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_124\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Tuberculose<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_10_124'><div class='gchoice gchoice_10_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Oui'  id='choice_10_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_124_1' id='label_10_124_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='No'  id='choice_10_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_124_2' id='label_10_124_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_10_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >VIH\/SIDA<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_10_43'><div class='gchoice gchoice_10_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Oui'  id='choice_10_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_43_1' id='label_10_43_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_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_10_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_43_2' id='label_10_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_10_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >H\u00e9patite A, B, C<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_10_44'><div class='gchoice gchoice_10_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Oui'  id='choice_10_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_44_1' id='label_10_44_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_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_10_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_44_2' id='label_10_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><div id=\"field_10_156\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_156'>Toute th\u00e9rapie\/condition qui pourrait affecter votre syst\u00e8me immunitaire<\/label><div class='ginput_container ginput_container_text'><input name='input_156' id='input_10_156' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_157\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_157'>Y a-t-il d\u2019autres conditions\/maladies non list\u00e9es que vous avez ou avez eues ?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_10_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_158\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_158'>6. Veuillez lister tous les m\u00e9dicaments sur ordonnance, en vente libre ou suppl\u00e9ments naturels que vous prenez actuellement, (avec les doses)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_158' id='input_10_158' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_159\" class=\"gfield gfield--type-html gfield--input-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\"  >7. Avez-vous des allergies ou des effets secondaires \u00e0 <\/div><div id=\"field_10_160\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_160'>M\u00e9dicaments<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_10_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_161'>Saisonniers, aliments<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_10_161' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_162'>8. Prenez-vous ou avez-vous d\u00e9j\u00e0 pris des m\u00e9dicaments ou des injections pour le cancer ou vos os (Par exemple, Biphosphonate ou Prolia)?<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_10_162' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_219\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >9. Prenez-vous de l\u2019aspirine\/ASA?<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_10_219'><div class='gchoice gchoice_10_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Oui'  id='choice_10_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_219_1' id='label_10_219_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='No'  id='choice_10_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_219_2' id='label_10_219_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_220\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_220'>10. Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9(e) pour des maladies graves ou des interventions chirurgicales ? Si oui, veuillez en dresser la liste avec le type et la date.<\/label><div class='ginput_container ginput_container_text'><input name='input_220' id='input_10_220' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_221\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >11. Fumez-vous des cigarettes, des cigares ou utilisez-vous une cigarette \u00e9lectronique ?<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_10_221'><div class='gchoice gchoice_10_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Oui'  id='choice_10_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_221_1' id='label_10_221_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='No'  id='choice_10_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_221_2' id='label_10_221_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_201\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_201'>Si oui \u00e0 l\u2019une des options ci-dessus, laquelle et combien ?<\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_10_201' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_202\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_202'>Avez-vous r\u00e9cemment arr\u00eat\u00e9 ? Quand?<\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_10_202' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_170\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >12. Consommez-vous de l\u2019alcool ?<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_10_170'><div class='gchoice gchoice_10_170_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.1' type='checkbox'  value='Oui'  id='choice_10_170_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_170_1' id='label_10_170_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_170_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.2' type='checkbox'  value='No'  id='choice_10_170_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_170_2' id='label_10_170_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_204'>Si oui, combien de verres par jour\/semaine ?<\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_10_204' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_222\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_222'>Quel type d\u2019alcool<\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_10_222' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_223\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >13. Consommez-vous des drogues r\u00e9cr\u00e9atives ? (Cannabis, coca\u00efne, etc.) ?<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_10_223'><div class='gchoice gchoice_10_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Oui'  id='choice_10_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_223_1' id='label_10_223_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='No'  id='choice_10_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_223_2' id='label_10_223_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_206\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_206'>Si oui, quel type de drogue et combien par jour ?<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_10_206' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_203\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >14. \u00cates-vous nerveux pendant le traitement dentaire ?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_203'><div class='gchoice gchoice_10_203_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.1' type='checkbox'  value='Oui'  id='choice_10_203_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_203_1' id='label_10_203_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_203_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.2' type='checkbox'  value='No'  id='choice_10_203_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_203_2' id='label_10_203_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_10_224\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >15. Voulez-vous discuter les options de s\u00e9dation?<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_10_224'><div class='gchoice gchoice_10_224_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.1' type='checkbox'  value='Oui'  id='choice_10_224_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_224_1' id='label_10_224_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_224_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.2' type='checkbox'  value='No'  id='choice_10_224_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_224_2' id='label_10_224_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_10_171\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >16. Pour les femmes : Allaitez-vous ou \u00eates-vous enceinte ?<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_10_171'><div class='gchoice gchoice_10_171_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_171.1' type='checkbox'  value='Oui'  id='choice_10_171_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_171_1' id='label_10_171_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_171_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_171.2' type='checkbox'  value='No'  id='choice_10_171_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_171_2' id='label_10_171_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_172\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_172'>Si vous \u00eates enceinte, quelle est la date pr\u00e9vue d\u2019accouchement ?<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_10_172' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_225\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >17. Brossez-vous vos dents \u00e0 tous les jours?<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_10_225'><div class='gchoice gchoice_10_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Oui'  id='choice_10_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_225_1' id='label_10_225_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='No'  id='choice_10_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_225_2' id='label_10_225_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_226\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_226'>\u00e0 quelle fr\u00e9quence<\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_10_226' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_227\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >18. Quel type de brosse \u00e0 dents utilisez-vous?<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_10_227'><div class='gchoice gchoice_10_227_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.1' type='checkbox'  value='Manuel'  id='choice_10_227_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_227_1' id='label_10_227_1' class='gform-field-label gform-field-label--type-inline'>Manuel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_227_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_227.2' type='checkbox'  value='\u00e9lectrique'  id='choice_10_227_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_227_2' id='label_10_227_2' class='gform-field-label gform-field-label--type-inline'>\u00e9lectrique<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_228\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >19. Utilisez vous de le soie dentaire, irrigateur ou brossette interproximale<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_10_228'><div class='gchoice gchoice_10_228_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_228.1' type='checkbox'  value='Oui'  id='choice_10_228_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_228_1' id='label_10_228_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_228_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_228.2' type='checkbox'  value='No'  id='choice_10_228_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_228_2' id='label_10_228_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_229\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_229'>Si oui, lesquels et \u00e0 quelle fr\u00e9quence?<\/label><div class='ginput_container ginput_container_text'><input name='input_229' id='input_10_229' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_139\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >20.  \u00c0 quelle fr\u00e9quence consultez-vous le dentiste\/l\u2019hygi\u00e9niste ?<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_10_139'><div class='gchoice gchoice_10_139_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.1' type='checkbox'  value='3 mois'  id='choice_10_139_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_1' id='label_10_139_1' class='gform-field-label gform-field-label--type-inline'>3 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_139_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.2' type='checkbox'  value='4 mois'  id='choice_10_139_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_2' id='label_10_139_2' class='gform-field-label gform-field-label--type-inline'>4 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_139_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.3' type='checkbox'  value='6 mois'  id='choice_10_139_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_3' id='label_10_139_3' class='gform-field-label gform-field-label--type-inline'>6 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_139_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.4' type='checkbox'  value='9 mois'  id='choice_10_139_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_4' id='label_10_139_4' class='gform-field-label gform-field-label--type-inline'>9 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_139_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.5' type='checkbox'  value='12 mois'  id='choice_10_139_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_5' id='label_10_139_5' class='gform-field-label gform-field-label--type-inline'>12 mois<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_139_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_139.6' type='checkbox'  value='Plus d&#039;1 an'  id='choice_10_139_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_139_6' id='label_10_139_6' class='gform-field-label gform-field-label--type-inline'>Plus d'1 an<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_230\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_230'>Quand remonte votre dernier nettoyage?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_230' id='input_10_230' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_173\" class=\"gfield gfield--type-html gfield--input-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\"  >\u00c0 ma connaissance, les informations ci-dessus sont correctes :<\/div><div id=\"field_10_174\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_174'>Patient\/Parent\/Tuteur\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_10_174' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_190\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_190'>Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_190' id='input_10_190' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_190_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_190_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_190' class='gform_hidden' value='https:\/\/www.ottawaperiodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_191\" class=\"gfield gfield--type-html gfield--input-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\"  >Signature du dentiste<\/div><div id=\"field_10_192\" class=\"gfield gfield--type-html gfield--input-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\"  >Date de signature du dentiste:\n<\/div><div id=\"field_10_231\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  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