{"id":488,"date":"2017-01-08T15:46:24","date_gmt":"2017-01-08T15:46:24","guid":{"rendered":"https:\/\/delvi.nl\/?page_id=488"},"modified":"2023-05-17T14:25:11","modified_gmt":"2023-05-17T14:25:11","slug":"intake-vragenlijst","status":"publish","type":"page","link":"https:\/\/delvi.nl\/en\/practice\/registration\/intake-questionnaire\/","title":{"rendered":"Intake questionnaire"},"content":{"rendered":"<script type=\"text\/javascript\">var 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Intake vragenlijst<\/h3>\n                            <p class='gform_description'>Voor je aanmelding bij Verloskundig Centrum DelVi hebben wij persoonlijke gegevens nodig. In verband met de integrale zorg, een nauwe samenwerking met het Reinier de Graaf ziekenhuis, is dit een hele uitgebreide vragenlijst. Het invullen hiervan zal ongeveer 10-15 minuten in beslag nemen. Het is van groot belang dat je de lijst zo volledig mogelijk invult. Uw gegevens worden verstuurd binnen een beveiligde omgeving. Wij zullen uw gegevens niet zonder uw toestemming verstrekken aan derden. Indien er onduidelijkheden zijn kan je contact opnemen of de vraag open laten en stellen bij de eerste controle.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/en\/wp-json\/wp\/v2\/pages\/488' data-formid='4' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/488\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_4_189\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_189\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_4_188\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_188\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_4_188'>\n                            \n                            <span id='input_4_188_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_188.3' id='input_4_188_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_188_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            <span id='input_4_188_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_188.4' id='input_4_188_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_188_4' class='gform-field-label gform-field-label--type-sub'>Tussenvoegsel<\/label>\n                                                <\/span>\n                            <span id='input_4_188_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_188.6' id='input_4_188_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_188_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_202\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_202\"><label class='gfield_label gform-field-label' for='input_4_202' >Voorletters:<\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_4_202' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_190\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_190\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_190' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_4_190_2_container'>\n                                            <input type='text' maxlength='2' name='input_190[]' id='input_4_190_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_4_190_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_4_190_1_container'>\n                                        <input type='text' maxlength='2' name='input_190[]' id='input_4_190_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_4_190_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_4_190_3_container'>\n                                        <input type='text' maxlength='4' name='input_190[]' id='input_4_190_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_4_190_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_4_205\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_205\"><label class='gfield_label gform-field-label' for='input_4_205' >Telefoonnummer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_4_205' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_1\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_1\"><h2 class=\"gsection_title\">Werk<\/h2><\/li><li id=\"field_4_196\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_196\"><label class='gfield_label gform-field-label' for='input_4_196' >Doet u staand werk?<\/label><div class='ginput_container ginput_container_select'><select name='input_196' id='input_4_196' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_4\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_4\"><label class='gfield_label gform-field-label' for='input_4_4' >Is dit onregelmatig werk of draait u nachtdiensten?<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_4_4' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_206\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_206\"><label class='gfield_label gform-field-label' for='input_4_206' >Werkt u met, of komt u vaak in contact met kleine kinderen?<\/label><div class='ginput_container ginput_container_select'><select name='input_206' id='input_4_206' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_5\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_5\"><label class='gfield_label gform-field-label' for='input_4_5' >Heeft u met radioactieve stoffen of ioniserende straling te maken?<\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_4_5' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_6\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_6\"><h2 class=\"gsection_title\">Gezondheid<\/h2><\/li><li id=\"field_4_7\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_7\"><label class='gfield_label gform-field-label' for='input_4_7' >Gebruikt u foliumzuur?<\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_4_7' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_197\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_197\"><label class='gfield_label gform-field-label' for='input_4_197' >Zo ja, sinds wanneer?<\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_4_197' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_9\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_9\"><label class='gfield_label gform-field-label' for='input_4_9' >Gebruikt u multivitamine?<\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_4_9' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_10\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_10\"><label class='gfield_label gform-field-label' for='input_4_10' >Zo ja, sinds wanneer?<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_11\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_11\"><label class='gfield_label gform-field-label' for='input_4_11' >Rookt u?<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_4_11' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_12\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_12\"><label class='gfield_label gform-field-label' for='input_4_12' >Zo ja, hoeveel per dag v\u00f3\u00f3r de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_12\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_12'>aantal sigaretten per dag <\/div><\/li><li id=\"field_4_13\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_13\"><label class='gfield_label gform-field-label' for='input_4_13' >Zo ja, hoeveel per dag in de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_13\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_13'>aantal sigaretten per dag<\/div><\/li><li id=\"field_4_14\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_14\"><label class='gfield_label gform-field-label' for='input_4_14' >Gebruikt u alcohol?<\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_4_14' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_18\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_18\"><label class='gfield_label gform-field-label' for='input_4_18' >Zo ja, hoeveel glazen per week v\u00f3\u00f3r de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_4_18' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_18\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_18'>aantal glazen per week<\/div><\/li><li id=\"field_4_16\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_16\"><label class='gfield_label gform-field-label' for='input_4_16' >Zo ja, hoeveel glazen per week in de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_4_16' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_16\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_16'>aantal glazen per week<\/div><\/li><li id=\"field_4_17\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_17\"><label class='gfield_label gform-field-label' for='input_4_17' >Gebruikt u drugs?<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_4_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_15\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_15\"><label class='gfield_label gform-field-label' for='input_4_15' >Zo ja, welke?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_19\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_19\"><label class='gfield_label gform-field-label' for='input_4_19' >Zo ja, hoe vaak per week v\u00f3\u00f3r de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_20\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_20\"><label class='gfield_label gform-field-label' for='input_4_20' >Zo ja, hoe vaak per week in de zwangerschap?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_21\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_21\"><label class='gfield_label gform-field-label' for='input_4_21' >Gebruikt u medicijnen?<\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_4_21' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_22\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_22\"><label class='gfield_label gform-field-label' for='input_4_22' >Zo ja, welke?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_4_22' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_23\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_23\"><label class='gfield_label gform-field-label' for='input_4_23' >Sinds wanneer?<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_4_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_24\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_24\"><label class='gfield_label gform-field-label' for='input_4_24' >Welke dosering?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_25\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_25\"><label class='gfield_label gform-field-label' for='input_4_25' >Eet u dagelijks groenten en fruit?<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_4_25' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Alleen groenten' >Alleen groenten<\/option><option value='Alleen fruit' >Alleen fruit<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_26\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_26\"><label class='gfield_label gform-field-label' for='input_4_26' >Heeft u speciale eetgewoonten?<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_4_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Vegetarisch' >Vegetarisch<\/option><option value='Veganistisch' >Veganistisch<\/option><option value='Macrobiotisch' >Macrobiotisch<\/option><option value='Anders*' >Anders*<\/option><\/select><\/div><\/li><li id=\"field_4_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_27\"><label class='gfield_label gform-field-label' for='input_4_27' >Anders:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_4_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_28\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_28\"><label class='gfield_label gform-field-label' for='input_4_28' >Bent u gezond?<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_4_28' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_29\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_29\"><label class='gfield_label gform-field-label' for='input_4_29' >Bent u gevaccineerd tegen Rubella (Rode Hond)?<\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_4_29' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_30\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_30\"><label class='gfield_label gform-field-label' for='input_4_30' >Heeft u de waterpokken doorgemaakt?<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_4_30' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_31\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_31\"><label class='gfield_label gform-field-label' for='input_4_31' >Heeft u ooit een bloedtransfusie gehad?<\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_4_31' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_32\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_32\"><label class='gfield_label gform-field-label' for='input_4_32' >Bent u afgelopen 2 mnd. behandeld of opgenomen in een buitenlands ziekenhuis?<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_4_32' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_192\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_192\"><h2 class=\"gsection_title\">Heeft u op dit moment of in het verleden \u00e9\u00e9n van de volgende ziekten\/aandoeningen doorgemaakt?<\/h2><\/li><li id=\"field_4_34\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_34\"><label class='gfield_label gform-field-label' for='input_4_34' >Blaasontsteking?<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_4_34' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_36\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_36\"><label class='gfield_label gform-field-label'  >Zo ja, hoe vaak?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_36'>\n\t\t\t<li class='gchoice gchoice_4_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Sporadisch'  id='choice_4_36_0'    \/>\n\t\t\t\t<label for='choice_4_36_0' id='label_4_36_0' class='gform-field-label gform-field-label--type-inline'>Sporadisch<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='1-2 keer per jaar'  id='choice_4_36_1'    \/>\n\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>1-2 keer per jaar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='vaker'  id='choice_4_36_2'    \/>\n\t\t\t\t<label for='choice_4_36_2' id='label_4_36_2' class='gform-field-label gform-field-label--type-inline'>vaker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_37\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_37\"><label class='gfield_label gform-field-label' for='input_4_37' >Vaginale schimmelinfectie (Candida)?<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_4_37' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_38\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_38\"><label class='gfield_label gform-field-label'  >Zo ja, hoe vaak?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_38'>\n\t\t\t<li class='gchoice gchoice_4_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Sporadisch'  id='choice_4_38_0'    \/>\n\t\t\t\t<label for='choice_4_38_0' id='label_4_38_0' class='gform-field-label gform-field-label--type-inline'>Sporadisch<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='1-2 keer per jaar'  id='choice_4_38_1'    \/>\n\t\t\t\t<label for='choice_4_38_1' id='label_4_38_1' class='gform-field-label gform-field-label--type-inline'>1-2 keer per jaar<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_38_2'>\n\t\t\t\t<input name='input_38' type='radio' value='vaker'  id='choice_4_38_2'    \/>\n\t\t\t\t<label for='choice_4_38_2' id='label_4_38_2' class='gform-field-label gform-field-label--type-inline'>vaker<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_39\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_39\"><label class='gfield_label gform-field-label' for='input_4_39' >Tandvleesontsteking?<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_4_39' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_40\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_40\"><label class='gfield_label gform-field-label' for='input_4_40' >Allergie\u00ebn?<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_4_40' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_41\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_41\"><label class='gfield_label gform-field-label' for='input_4_41' >Zo ja, waarvoor?<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_4_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_42\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_42\"><label class='gfield_label gform-field-label' for='input_4_42' >Koortslip?<\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_4_42' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_43\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_43\"><label class='gfield_label gform-field-label' for='input_4_43' >Suikerziekte?<\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_4_43' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_44\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_44\"><label class='gfield_label gform-field-label' for='input_4_44' >Hoge bloeddruk?<\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_4_44' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_45\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_45\"><label class='gfield_label gform-field-label' for='input_4_45' >Schildklieraandoening?<\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_4_45' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_46\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_46\"><label class='gfield_label gform-field-label' for='input_4_46' >Trombose?<\/label><div class='ginput_container ginput_container_select'><select name='input_46' id='input_4_46' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_47\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_47\"><label class='gfield_label gform-field-label' for='input_4_47' >Krijgt u snel blauwe plekken of blijven wondjes lang nabloeden?<\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_4_47' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_48\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_48\"><label class='gfield_label gform-field-label' for='input_4_48' >Hart en vaatziekte?<\/label><div class='ginput_container ginput_container_select'><select name='input_48' id='input_4_48' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_49\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_49\"><label class='gfield_label gform-field-label' for='input_4_49' >Lever of nierziekte?<\/label><div class='ginput_container ginput_container_select'><select name='input_49' id='input_4_49' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_50\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_50\"><label class='gfield_label gform-field-label' for='input_4_50' >Epilepsie?<\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_4_50' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_51\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_51\"><label class='gfield_label gform-field-label' for='input_4_51' >Kanker?<\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_4_51' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_52\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_52\"><label class='gfield_label gform-field-label' for='input_4_52' >Astma\/chronische bronchitis (CARA)?<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_4_52' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_53\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_53\"><label class='gfield_label gform-field-label' for='input_4_53' >Reumatische aandoeningen?<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_4_53' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_54\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_54\"><label class='gfield_label gform-field-label' for='input_4_54' >Eetstoornissen?<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_4_54' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_55\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_55\"><label class='gfield_label gform-field-label' for='input_4_55' >Bent u onder behandeling (geweest) van een medisch specialist?<\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_4_55' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_56\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_56\"><label class='gfield_label gform-field-label' for='input_4_56' >Zo ja, bij welke specialist?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_4_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_57\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_57\"><label class='gfield_label gform-field-label' for='input_4_57' >Naam ziekenhuis:<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_4_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_199\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_199\"><label class='gfield_label gform-field-label' for='input_4_199' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_4_199' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_60\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_60\"><label class='gfield_label gform-field-label' for='input_4_60' >Waarom?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_4_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_61\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_61\"><label class='gfield_label gform-field-label' for='input_4_61' >Bent u ooit geopereerd?<\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_4_61' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_62\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_62\"><label class='gfield_label gform-field-label' for='input_4_62' >Zo ja, door welke specialist?<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_4_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_63\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_63\"><label class='gfield_label gform-field-label' for='input_4_63' >Naam ziekenhuis:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_4_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_193\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_193\"><label class='gfield_label gform-field-label' for='input_4_193' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_65\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_65\"><label class='gfield_label gform-field-label' for='input_4_65' >Waaraan?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_4_65' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_194\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_194\"><label class='gfield_label gform-field-label' for='input_4_194' >Evt. verdere operaties?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_194' id='input_4_194' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_66\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_66\"><label class='gfield_label gform-field-label' for='input_4_66' >Bent u familie van de aanstaande vader?<\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_4_66' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_67\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_67\"><label class='gfield_label gform-field-label' for='input_4_67' >Zo ja, leg de familie band uit:<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_4_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_68\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_68\"><label class='gfield_label gform-field-label' for='input_4_68' >Heeft u een erfelijke of aangeboren ziekte(s)?<\/label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_4_68' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_69\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_69\"><label class='gfield_label gform-field-label' for='input_4_69' >Zo ja, welke ziekte(s)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_4_69' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_70\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_70\"><h2 class=\"gsection_title\">Psychosociale zorg<\/h2><\/li><li id=\"field_4_191\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_191\"><label class='gfield_label gform-field-label'  >Heeft u ooit contact gehad met:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_191'>\n\t\t\t<li class='gchoice gchoice_4_191_0'>\n\t\t\t\t<input name='input_191' type='radio' value='Maatschappelijk werk'  id='choice_4_191_0'    \/>\n\t\t\t\t<label for='choice_4_191_0' id='label_4_191_0' class='gform-field-label gform-field-label--type-inline'>Maatschappelijk werk<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_191_1'>\n\t\t\t\t<input name='input_191' type='radio' value='Psycholoog'  id='choice_4_191_1'    \/>\n\t\t\t\t<label for='choice_4_191_1' id='label_4_191_1' class='gform-field-label gform-field-label--type-inline'>Psycholoog<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_191_2'>\n\t\t\t\t<input name='input_191' type='radio' value='Psychiater'  id='choice_4_191_2'    \/>\n\t\t\t\t<label for='choice_4_191_2' id='label_4_191_2' class='gform-field-label gform-field-label--type-inline'>Psychiater<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_191_3'>\n\t\t\t\t<input name='input_191' type='radio' value='Jeugdzorg'  id='choice_4_191_3'    \/>\n\t\t\t\t<label for='choice_4_191_3' id='label_4_191_3' class='gform-field-label gform-field-label--type-inline'>Jeugdzorg<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_75\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_75\"><label class='gfield_label gform-field-label' for='input_4_75' >Zo ja, wanneer?<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_4_75' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_73\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_73\"><label class='gfield_label gform-field-label' for='input_4_73' >Zo ja, wat was de reden:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_4_73' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_74\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_74\"><label class='gfield_label gform-field-label' for='input_4_74' >Heeft u weleens psychiatrische medicatie gebruikt?<\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_4_74' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_200\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_200\"><label class='gfield_label gform-field-label' for='input_4_200' >Zo ja, welke?<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_4_200' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_201\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_201\"><label class='gfield_label gform-field-label' for='input_4_201' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_201' id='input_4_201' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_77\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_77\"><label class='gfield_label gform-field-label' for='input_4_77' >Voor hoelang?<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_4_77' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_77\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_77'>aantal maanden<\/div><\/li><li id=\"field_4_78\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_78\"><label class='gfield_label gform-field-label' for='input_4_78' >Ervaart u voldoende steun uit uw omgeving?<\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_4_78' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_79\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_79\"><label class='gfield_label gform-field-label' for='input_4_79' >Bent u ooit mishandeld?<\/label><div class='ginput_container ginput_container_select'><select name='input_79' id='input_4_79' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_80\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_80\"><label class='gfield_label gform-field-label' for='input_4_80' >Bent u getuige geweest van mishandeling?<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_4_80' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_81\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_81\"><label class='gfield_label gform-field-label' for='input_4_81' >Heeft u ooit iets vervelends meegemaakt op sexueel gebied?<\/label><div class='ginput_container ginput_container_select'><select name='input_81' id='input_4_81' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_82\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_82\"><label class='gfield_label gform-field-label' for='input_4_82' >Heeft u ooit een negatieve ervaring gehad mbt gezondheidszorg\/hulpverlening?<\/label><div class='ginput_container ginput_container_select'><select name='input_82' id='input_4_82' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_83\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_83\"><h2 class=\"gsection_title\">Familie anamnese<\/h2><\/li><li id=\"field_4_84\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_84\"><label class='gfield_label gform-field-label' for='input_4_84' >Is uw partner gezond?<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_4_84' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_85\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_85\"><label class='gfield_label gform-field-label' for='input_4_85' >Zo nee, licht toe:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_4_85' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_86\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_86\"><label class='gfield_label gform-field-label' for='input_4_86' >Rookt uw partner?<\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_4_86' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_87\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_87\"><label class='gfield_label gform-field-label' for='input_4_87' >Zo ja, rookt uw partner binnenshuis?<\/label><div class='ginput_container ginput_container_select'><select name='input_87' id='input_4_87' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_88\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_88\"><label class='gfield_label gform-field-label' for='input_4_88' >Heeft uw partner weleens een koortslip?<\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_4_88' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_89\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_89\"><label class='gfield_label gform-field-label' for='input_4_89' >Heeft uw partner een erfelijke of aangeboren ziekte(s)?<\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_4_89' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_90\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_90\"><label class='gfield_label gform-field-label' for='input_4_90' >Zo ja, welke ziekte?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_4_90' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_198\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_198\"><h2 class=\"gsection_title\">Komen er bij u of bij de aanstaande vader in de familie een van de volgende aandoeningen voor?<\/h2><\/li><li id=\"field_4_92\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_92\"><label class='gfield_label gform-field-label' for='input_4_92' >Hoge bloeddruk?<\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_4_92' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_93\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_93\"><label class='gfield_label gform-field-label' for='input_4_93' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_4_93' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_94\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_94\"><label class='gfield_label gform-field-label' for='input_4_94' >Suikerziekte?<\/label><div class='ginput_container ginput_container_select'><select name='input_94' id='input_4_94' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_95\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_95\"><label class='gfield_label gform-field-label' for='input_4_95' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_96\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_96\"><label class='gfield_label gform-field-label' for='input_4_96' >Familiaire bloedarmoede (Thalassemie\/sikkelcelziekte)<\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_4_96' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_97\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_97\"><label class='gfield_label gform-field-label' for='input_4_97' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_4_97' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_98\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_98\"><label class='gfield_label gform-field-label' for='input_4_98' >Stollingsziekte\/hemofilie?<\/label><div class='ginput_container ginput_container_select'><select name='input_98' id='input_4_98' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_99\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_99\"><label class='gfield_label gform-field-label' for='input_4_99' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_4_99' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_100\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_100\"><label class='gfield_label gform-field-label' for='input_4_100' >Aangeboren blindheid of slechtziendheid?<\/label><div class='ginput_container ginput_container_select'><select name='input_100' id='input_4_100' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_101\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_101\"><label class='gfield_label gform-field-label' for='input_4_101' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_4_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_102\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_102\"><label class='gfield_label gform-field-label' for='input_4_102' >Aangeboren doofheid?<\/label><div class='ginput_container ginput_container_select'><select name='input_102' id='input_4_102' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_103\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_103\"><label class='gfield_label gform-field-label' for='input_4_103' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_4_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_104\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_104\"><label class='gfield_label gform-field-label' for='input_4_104' >Hartafwijkingen?<\/label><div class='ginput_container ginput_container_select'><select name='input_104' id='input_4_104' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_105\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_105\"><label class='gfield_label gform-field-label' for='input_4_105' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_4_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_106\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_106\"><label class='gfield_label gform-field-label' for='input_4_106' >Aandoeningen van de hersenen\/zenuwstelsel?<\/label><div class='ginput_container ginput_container_select'><select name='input_106' id='input_4_106' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_107\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_107\"><label class='gfield_label gform-field-label' for='input_4_107' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_4_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_108\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_108\"><label class='gfield_label gform-field-label' for='input_4_108' >Heupafwijkingen?<\/label><div class='ginput_container ginput_container_select'><select name='input_108' id='input_4_108' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_109\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_109\"><label class='gfield_label gform-field-label' for='input_4_109' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_4_109' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_110\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_110\"><label class='gfield_label gform-field-label' for='input_4_110' >Spierziekten?<\/label><div class='ginput_container ginput_container_select'><select name='input_110' id='input_4_110' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_111\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_111\"><label class='gfield_label gform-field-label' for='input_4_111' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_4_111' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_112\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_112\"><label class='gfield_label gform-field-label' for='input_4_112' >Lip- of gehemeltespleet?<\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_4_112' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_113\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_113\"><label class='gfield_label gform-field-label' for='input_4_113' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_4_113' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_114\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_114\"><label class='gfield_label gform-field-label' for='input_4_114' >Open rug (spina bifida), open schedel (anencefalie), waterhoofd?<\/label><div class='ginput_container ginput_container_select'><select name='input_114' id='input_4_114' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_115\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_115\"><label class='gfield_label gform-field-label' for='input_4_115' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_4_115' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_116\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_116\"><label class='gfield_label gform-field-label' for='input_4_116' >Downsyndroom?<\/label><div class='ginput_container ginput_container_select'><select name='input_116' id='input_4_116' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_117\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_117\"><label class='gfield_label gform-field-label' for='input_4_117' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_4_117' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_118\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_118\"><label class='gfield_label gform-field-label' for='input_4_118' >Vertraagde verstandelijke ontwikkeling (bijv. Fragiele-X-syndroom)?<\/label><div class='ginput_container ginput_container_select'><select name='input_118' id='input_4_118' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_119\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_119\"><label class='gfield_label gform-field-label' for='input_4_119' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_4_119' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_120\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_120\"><label class='gfield_label gform-field-label' for='input_4_120' >Andere aangeboren- of erfelijke afwijkingen?<\/label><div class='ginput_container ginput_container_select'><select name='input_120' id='input_4_120' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_121\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_121\"><label class='gfield_label gform-field-label' for='input_4_121' >Zo ja, welke afwijkingen?<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_4_121' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_122\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_122\"><h2 class=\"gsection_title\">Financi\u00ebn<\/h2><\/li><li id=\"field_4_123\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_123\"><label class='gfield_label gform-field-label' for='input_4_123' >Heeft u en\/of uw partner samen een inkomen lager dan \u20ac2000,- per maand?<\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_4_123' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_124\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_124\"><label class='gfield_label gform-field-label' for='input_4_124' >Zijn er financi\u00eble zorgen?<\/label><div class='ginput_container ginput_container_select'><select name='input_124' id='input_4_124' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_125\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_125\"><label class='gfield_label gform-field-label' for='input_4_125' >Zo ja, heeft u hier hulp voor?<\/label><div class='ginput_container ginput_container_select'><select name='input_125' id='input_4_125' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><option value='Nvt' >Nvt<\/option><\/select><\/div><\/li><li id=\"field_4_126\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_126\"><h2 class=\"gsection_title\">Verloskundige en gynaecologische voorgeschiedenis<\/h2><\/li><li id=\"field_4_127\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_127\"><label class='gfield_label gform-field-label' for='input_4_127' >Heeft u kinderen?<\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_4_127' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_4_128\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_128\"><label class='gfield_label gform-field-label' for='input_4_128' >Geboortedatum kind 1<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_128' id='input_4_128' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_4_128_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_128_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_128' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_133\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_133\"><label class='gfield_label gform-field-label' for='input_4_133' >Waar bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_4_133' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_134\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_134\"><label class='gfield_label gform-field-label' for='input_4_134' >Zwangerschapsduur<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_4_134' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_134\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_134'>&#8230;weken&#8230;dagen<\/div><\/li><li id=\"field_4_135\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_135\"><label class='gfield_label gform-field-label'  >Geslacht<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_135'>\n\t\t\t<li class='gchoice gchoice_4_135_0'>\n\t\t\t\t<input name='input_135' type='radio' value='Jongen'  id='choice_4_135_0'    \/>\n\t\t\t\t<label for='choice_4_135_0' id='label_4_135_0' class='gform-field-label gform-field-label--type-inline'>Jongen<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_135_1'>\n\t\t\t\t<input name='input_135' type='radio' value='Meisje'  id='choice_4_135_1'    \/>\n\t\t\t\t<label for='choice_4_135_1' id='label_4_135_1' class='gform-field-label gform-field-label--type-inline'>Meisje<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_136\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_136\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_136'>\n                            \n                            <span id='input_4_136_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_136.3' id='input_4_136_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_136_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_136_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_136.6' id='input_4_136_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_136_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_4_136'>Kind 1<\/div><\/li><li id=\"field_4_149\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_149\"><label class='gfield_label gform-field-label' for='input_4_149' >Geboortegewicht<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_4_149' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_149\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_149'>Kind 1<\/div><\/li><li id=\"field_4_160\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_160\"><label class='gfield_label gform-field-label' for='input_4_160' >Hoe bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_4_160' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_160\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_160'>Kind 1<\/div><\/li><li id=\"field_4_156\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_156\"><label class='gfield_label gform-field-label' for='input_4_156' >Bijzonderheden<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_156' id='input_4_156' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_129\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_129\"><label class='gfield_label gform-field-label' for='input_4_129' >Geboortedatum kind 2<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_129' id='input_4_129' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_4_129_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_129_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_129' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_137\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_137\"><label class='gfield_label gform-field-label' for='input_4_137' >Waar bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_4_137' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_140\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_140\"><label class='gfield_label gform-field-label' for='input_4_140' >Zwangerschapsduur<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_4_140' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_140\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_140'>&#8230;weken&#8230;dagen<\/div><\/li><li id=\"field_4_143\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_143\"><label class='gfield_label gform-field-label'  >Geslacht<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_143'>\n\t\t\t<li class='gchoice gchoice_4_143_0'>\n\t\t\t\t<input name='input_143' type='radio' value='Jongen'  id='choice_4_143_0'    \/>\n\t\t\t\t<label for='choice_4_143_0' id='label_4_143_0' class='gform-field-label gform-field-label--type-inline'>Jongen<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_143_1'>\n\t\t\t\t<input name='input_143' type='radio' value='Meisje'  id='choice_4_143_1'    \/>\n\t\t\t\t<label for='choice_4_143_1' id='label_4_143_1' class='gform-field-label gform-field-label--type-inline'>Meisje<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_146\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_146\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_146'>\n                            \n                            <span id='input_4_146_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_146.3' id='input_4_146_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_146_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_146_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_146.6' id='input_4_146_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_146_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_4_146'>Kind 2<\/div><\/li><li id=\"field_4_152\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_152\"><label class='gfield_label gform-field-label' for='input_4_152' >Geboortegewicht<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_4_152' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_152\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_152'>Kind 2<\/div><\/li><li id=\"field_4_165\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_165\"><label class='gfield_label gform-field-label' for='input_4_165' >Hoe bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_4_165' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_165\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_165'>Kind 2<\/div><\/li><li id=\"field_4_157\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_157\"><label class='gfield_label gform-field-label' for='input_4_157' >Bijzonderheden?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_157' id='input_4_157' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_130\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_130\"><label class='gfield_label gform-field-label' for='input_4_130' >Geboortedatum kind 3<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_130' id='input_4_130' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_4_130_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_130_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_130' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_138\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_138\"><label class='gfield_label gform-field-label' for='input_4_138' >Waar bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_4_138' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_141\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_141\"><label class='gfield_label gform-field-label' for='input_4_141' >Zwangerschapsduur<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_4_141' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_141\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_141'>&#8230;weken&#8230;dagen<\/div><\/li><li id=\"field_4_144\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_144\"><label class='gfield_label gform-field-label'  >Geslacht<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_144'>\n\t\t\t<li class='gchoice gchoice_4_144_0'>\n\t\t\t\t<input name='input_144' type='radio' value='Jongen'  id='choice_4_144_0'    \/>\n\t\t\t\t<label for='choice_4_144_0' id='label_4_144_0' class='gform-field-label gform-field-label--type-inline'>Jongen<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_144_1'>\n\t\t\t\t<input name='input_144' type='radio' value='Meisje'  id='choice_4_144_1'    \/>\n\t\t\t\t<label for='choice_4_144_1' id='label_4_144_1' class='gform-field-label gform-field-label--type-inline'>Meisje<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_147\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_147\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_147'>\n                            \n                            <span id='input_4_147_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_147.3' id='input_4_147_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_147_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_147_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_147.6' id='input_4_147_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_147_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_4_147'>Kind 3<\/div><\/li><li id=\"field_4_151\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_151\"><label class='gfield_label gform-field-label' for='input_4_151' >Geboortegewicht<\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_4_151' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_151\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_151'>Kind 3<\/div><\/li><li id=\"field_4_163\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_163\"><label class='gfield_label gform-field-label' for='input_4_163' >Hoe bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_4_163' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_163\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_163'>Kind 3<\/div><\/li><li id=\"field_4_164\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_164\"><label class='gfield_label gform-field-label' for='input_4_164' >Bijzonderheden?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_164' id='input_4_164' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_131\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_131\"><label class='gfield_label gform-field-label' for='input_4_131' >Geboortedatum kind 4<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_131' id='input_4_131' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_4_131_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_131_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_131' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_139\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_139\"><label class='gfield_label gform-field-label' for='input_4_139' >Waar bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_4_139' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_142\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_142\"><label class='gfield_label gform-field-label' for='input_4_142' >Zwangerschapsduur<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_4_142' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_142\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_142'>&#8230;weken&#8230;dagen<\/div><\/li><li id=\"field_4_145\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_145\"><label class='gfield_label gform-field-label'  >Geslacht<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_145'>\n\t\t\t<li class='gchoice gchoice_4_145_0'>\n\t\t\t\t<input name='input_145' type='radio' value='Jongen'  id='choice_4_145_0'    \/>\n\t\t\t\t<label for='choice_4_145_0' id='label_4_145_0' class='gform-field-label gform-field-label--type-inline'>Jongen<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_145_1'>\n\t\t\t\t<input name='input_145' type='radio' value='Meisje'  id='choice_4_145_1'    \/>\n\t\t\t\t<label for='choice_4_145_1' id='label_4_145_1' class='gform-field-label gform-field-label--type-inline'>Meisje<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_148\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_148\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_148'>\n                            \n                            <span id='input_4_148_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_148.3' id='input_4_148_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_148_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_148_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_148.6' id='input_4_148_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_148_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_4_148'>Kind 4<\/div><\/li><li id=\"field_4_150\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_150\"><label class='gfield_label gform-field-label' for='input_4_150' >Geboortegewicht<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_4_150' type='text' value='' class='medium'  aria-describedby=\"gfield_description_4_150\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_4_150'>Kind 4<\/div><\/li><li id=\"field_4_161\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_161\"><label class='gfield_label gform-field-label' for='input_4_161' >Hoe bevallen?<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_4_161' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_162\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_162\"><label class='gfield_label gform-field-label' for='input_4_162' >Bijzonderheden?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_162' id='input_4_162' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_166\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_166\"><label class='gfield_label gform-field-label' for='input_4_166' >Heeft u een kind met een aangeboren afwijking\/aandoening?<\/label><div class='ginput_container ginput_container_select'><select name='input_166' id='input_4_166' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_167\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_167\"><label class='gfield_label gform-field-label' for='input_4_167' >Zo ja, welke aandoening?<\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_4_167' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_168\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_168\"><label class='gfield_label gform-field-label' for='input_4_168' >Zijn er \u00e9\u00e9n of meerdere kinderen nog in behandeling van een kinderarts?<\/label><div class='ginput_container ginput_container_select'><select name='input_168' id='input_4_168' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_169\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_169\"><label class='gfield_label gform-field-label' for='input_4_169' >Zo ja, bij wie?<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_4_169' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_170\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_170\"><label class='gfield_label gform-field-label' for='input_4_170' >Zo ja, waarvoor?<\/label><div class='ginput_container ginput_container_text'><input name='input_170' id='input_4_170' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_171\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_171\"><label class='gfield_label gform-field-label' for='input_4_171' >Zijn er kinderen die niet bij u in huis wonen?<\/label><div class='ginput_container ginput_container_select'><select name='input_171' id='input_4_171' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_172\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_172\"><label class='gfield_label gform-field-label' for='input_4_172' >Zo ja, wat is de reden?<\/label><div class='ginput_container ginput_container_text'><input name='input_172' id='input_4_172' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_173\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_173\"><label class='gfield_label gform-field-label' for='input_4_173' >Zijn er bij eerdere kinderen problemen op het gebied van gezondheid, jeugdzorg, opvoeding of anders?<\/label><div class='ginput_container ginput_container_select'><select name='input_173' id='input_4_173' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_174\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_174\"><label class='gfield_label gform-field-label' for='input_4_174' >Zo ja, kan u dat verder uitleggen:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_174' id='input_4_174' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_177\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_177\"><label class='gfield_label gform-field-label' for='input_4_177' >Heeft u ooit een buitenbaarmoederlijke zwangerschap doorgemaakt?<\/label><div class='ginput_container ginput_container_select'><select name='input_177' id='input_4_177' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_178\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_178\"><label class='gfield_label gform-field-label' for='input_4_178' >Zijn er ooit afwijkingen aan de baarmoeder of baarmoederhals geconstateerd?<\/label><div class='ginput_container ginput_container_select'><select name='input_178' id='input_4_178' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_179\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_179\"><label class='gfield_label gform-field-label' for='input_4_179' >Indien ja, welke:<\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_4_179' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_180\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_180\"><label class='gfield_label gform-field-label' for='input_4_180' >Heeft u ooit een uitstrijkje laten maken?<\/label><div class='ginput_container ginput_container_select'><select name='input_180' id='input_4_180' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_182\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_182\"><label class='gfield_label gform-field-label' for='input_4_182' >Indien ja, wanneer?<\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_4_182' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_195\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_195\"><label class='gfield_label gform-field-label' for='input_4_195' >Uitslag:<\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_4_195' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_183\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_183\"><label class='gfield_label gform-field-label' for='input_4_183' >Heeft u ooit een geslachtsziekte gehad (SOA)?<\/label><div class='ginput_container ginput_container_select'><select name='input_183' id='input_4_183' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_184\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_184\"><label class='gfield_label gform-field-label' for='input_4_184' >Indien ja, welke:<\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_4_184' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_185\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_185\"><label class='gfield_label gform-field-label' for='input_4_185' >Wie was de behandelaar?<\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_4_185' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_4_186\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_186\"><label class='gfield_label gform-field-label' for='input_4_186' >Bent u besneden?<\/label><div class='ginput_container ginput_container_select'><select name='input_186' id='input_4_186' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_4_187\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_187\"><label class='gfield_label gform-field-label' for='input_4_187' >Eventuele verdere mededelingen\/bijzonderheden\/vragen<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_187' id='input_4_187' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_207\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_4_207\"><label class='gfield_label gform-field-label' for='input_4_207' >Email<\/label><div class='ginput_container'><input name='input_207' id='input_4_207' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_4_207'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' value='Versturen'  onclick='if(window[\"gf_submitting_4\"]){return false;}  window[\"gf_submitting_4\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_4\"]){return false;} window[\"gf_submitting_4\"]=true;  jQuery(\"#gform_4\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='WyJbXSIsImIzODJiMzc5YmUzYTJjN2I1YWZlYWRjZTM1NTdjYWRiIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_4').val();gformInitSpinner( 4, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [4, current_page]);window['gf_submitting_4'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_4').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [4]);window['gf_submitting_4'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_4').text());}, 50);}else{jQuery('#gform_4').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [4, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 4, currentPage: current_page } });} );} );\n<\/script>\n\n\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><style>#gform_wrapper_3[data-form-index=\"0\"].gform-theme,[data-parent-form=\"3_0\"]{--gform-theme-color-primary: #204ce5;--gform-theme-color-primary-rgb: 32, 76, 229;--gform-theme-color-primary-contrast: #fff;--gform-theme-color-primary-contrast-rgb: 255, 255, 255;--gform-theme-color-primary-darker: #001AB3;--gform-theme-color-primary-lighter: #527EFF;--gform-theme-color-secondary: #fff;--gform-theme-color-secondary-rgb: 255, 255, 255;--gform-theme-color-secondary-contrast: #112337;--gform-theme-color-secondary-contrast-rgb: 17, 35, 55;--gform-theme-color-secondary-darker: #F5F5F5;--gform-theme-color-secondary-lighter: #FFFFFF;--gform-theme-color-outside-control-light: rgba(17, 35, 55, 0.1);--gform-theme-color-outside-control-light-rgb: 17, 35, 55;--gform-theme-color-outside-control-light-darker: rgba(104, 110, 119, 0.35);--gform-theme-color-outside-control-light-lighter: #F5F5F5;--gform-theme-color-outside-control-dark: #585e6a;--gform-theme-color-outside-control-dark-rgb: 88, 94, 106;--gform-theme-color-outside-control-dark-darker: #112337;--gform-theme-color-outside-control-dark-lighter: rgba(17, 35, 55, 0.65);--gform-theme-color-inside-control: #fff;--gform-theme-color-inside-control-rgb: 255, 255, 255;--gform-theme-color-inside-control-contrast: #112337;--gform-theme-color-inside-control-contrast-rgb: 17, 35, 55;--gform-theme-color-inside-control-darker: #F5F5F5;--gform-theme-color-inside-control-lighter: #FFFFFF;--gform-theme-color-inside-control-primary: #204ce5;--gform-theme-color-inside-control-primary-rgb: 32, 76, 229;--gform-theme-color-inside-control-primary-contrast: #fff;--gform-theme-color-inside-control-primary-contrast-rgb: 255, 255, 255;--gform-theme-color-inside-control-primary-darker: #001AB3;--gform-theme-color-inside-control-primary-lighter: #527EFF;--gform-theme-color-inside-control-light: rgba(17, 35, 55, 0.1);--gform-theme-color-inside-control-light-rgb: 17, 35, 55;--gform-theme-color-inside-control-light-darker: rgba(104, 110, 119, 0.35);--gform-theme-color-inside-control-light-lighter: #F5F5F5;--gform-theme-color-inside-control-dark: #585e6a;--gform-theme-color-inside-control-dark-rgb: 88, 94, 106;--gform-theme-color-inside-control-dark-darker: #112337;--gform-theme-color-inside-control-dark-lighter: rgba(17, 35, 55, 0.65);--gform-theme-border-radius: 3px;--gform-theme-font-size-secondary: 14px;--gform-theme-font-size-tertiary: 13px;--gform-theme-icon-control-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\");--gform-theme-icon-control-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\");--gform-theme-icon-control-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%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\");--gform-theme-control-border-color: #686e77;--gform-theme-control-size: var(--gform-theme-control-size-md);--gform-theme-control-label-color-primary: #112337;--gform-theme-control-label-color-secondary: #112337;--gform-theme-control-choice-size: var(--gform-theme-control-choice-size-md);--gform-theme-control-checkbox-check-size: var(--gform-theme-control-checkbox-check-size-md);--gform-theme-control-radio-check-size: var(--gform-theme-control-radio-check-size-md);--gform-theme-control-button-font-size: var(--gform-theme-control-button-font-size-md);--gform-theme-control-button-padding-inline: var(--gform-theme-control-button-padding-inline-md);--gform-theme-control-button-size: var(--gform-theme-control-button-size-md);--gform-theme-control-button-border-color-secondary: #686e77;--gform-theme-control-file-button-background-color-hover: #EBEBEB;--gform-theme-field-page-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Form 2. Intake questionnaire<\/h3>\n                            <p class='gform_description'>We need personal information for your registration at DelVi midwifery center. In connection with integrated care, close cooperation with the Reinier de Graaf hospital, this is a very extensive questionnaire. It will take approximately 10-15 minutes to complete. It is very important that you fill in the list as complete as possible. Your data will be sent within a secure environment. We will not provide your information to third parties without your consent. If there are any ambiguities, you can contact us or leave the question open and ask it during the first check. Thank you very much for your cooperation!<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/488' data-formid='3' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/488\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_3_2\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_2\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_3_4\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_4\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_4'>\n                            \n                            <span id='input_3_4_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.3' id='input_3_4_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_4_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_4_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_4.6' id='input_3_4_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_4_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_3_5\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Initials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub'>initials<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_3_11\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_11\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Maiden name (if applicable)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name no_last_name no_suffix gf_name_has_0 ginput_container_name gform-grid-row' id='input_3_11'>\n                            \n                            \n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_3_1\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_3_1' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_1_2_container'>\n                                            <input type='text' maxlength='2' name='input_1[]' id='input_3_1_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_3_1_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_1_1_container'>\n                                        <input type='text' maxlength='2' name='input_1[]' id='input_3_1_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_3_1_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_1_3_container'>\n                                        <input type='text' maxlength='4' name='input_1[]' id='input_3_1_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_3_6\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_6\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_3_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_3_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_3_6_1' id='input_3_6_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_3_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_3_6_2' id='input_3_6_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_3_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_3_6_3' id='input_3_6_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_3_6_4' value=''      aria-required='true'    \/>\n                                        <label for='input_3_6_4' id='input_3_6_4_label' class='gform-field-label gform-field-label--type-sub'>County \/ State \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_3_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_3_6_5' id='input_3_6_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_6.6' id='input_3_6_6' value='Netherlands' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_3_3\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_3\"><label class='gfield_label gform-field-label' for='input_3_3' >Burgerservicenummer (BSN)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_193\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_193\"><label class='gfield_label gform-field-label' for='input_3_193' >Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_3_193' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_12\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_12\"><h2 class=\"gsection_title\">Employment<\/h2><\/li><li id=\"field_3_13\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_13\"><label class='gfield_label gform-field-label'  >Do you have a job where you have to stand for long periods of time?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_13'>\n\t\t\t<li class='gchoice gchoice_3_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_3_13_0'    \/>\n\t\t\t\t<label for='choice_3_13_0' id='label_3_13_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes'  id='choice_3_13_1'    \/>\n\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_14\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_14\"><label class='gfield_label gform-field-label'  >Do you work with little children?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_14'>\n\t\t\t<li class='gchoice gchoice_3_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_3_14_0'    \/>\n\t\t\t\t<label for='choice_3_14_0' id='label_3_14_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes'  id='choice_3_14_1'    \/>\n\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_194\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_194\"><label class='gfield_label gform-field-label'  >Do you work unsocial hours or night shifts?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_194'>\n\t\t\t<li class='gchoice gchoice_3_194_0'>\n\t\t\t\t<input name='input_194' type='radio' value='No'  id='choice_3_194_0'    \/>\n\t\t\t\t<label for='choice_3_194_0' id='label_3_194_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_194_1'>\n\t\t\t\t<input name='input_194' type='radio' value='Yes'  id='choice_3_194_1'    \/>\n\t\t\t\t<label for='choice_3_194_1' id='label_3_194_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_15\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_15\"><label class='gfield_label gform-field-label'  >Are you at risk of exposure to radiaoctive substances or ionising radiation?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_15'>\n\t\t\t<li class='gchoice gchoice_3_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_3_15_0'    \/>\n\t\t\t\t<label for='choice_3_15_0' id='label_3_15_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_3_15_1'    \/>\n\t\t\t\t<label for='choice_3_15_1' id='label_3_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_16\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_16\"><h2 class=\"gsection_title\">Health<\/h2><\/li><li id=\"field_3_17\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_17\"><label class='gfield_label gform-field-label'  >Are you taking Folic Acid?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_17'>\n\t\t\t<li class='gchoice gchoice_3_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Yes'  id='choice_3_17_0'    \/>\n\t\t\t\t<label for='choice_3_17_0' id='label_3_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='No'  id='choice_3_17_1'    \/>\n\t\t\t\t<label for='choice_3_17_1' id='label_3_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_18\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_18\"><label class='gfield_label gform-field-label'  >Are you taking pregnancy vitamins?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_18'>\n\t\t\t<li class='gchoice gchoice_3_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Yes'  id='choice_3_18_0'    \/>\n\t\t\t\t<label for='choice_3_18_0' id='label_3_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='No'  id='choice_3_18_1'    \/>\n\t\t\t\t<label for='choice_3_18_1' id='label_3_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_19\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\"><label class='gfield_label gform-field-label'  >Do you smoke?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_19'>\n\t\t\t<li class='gchoice gchoice_3_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='No'  id='choice_3_19_0'    \/>\n\t\t\t\t<label for='choice_3_19_0' id='label_3_19_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Yes'  id='choice_3_19_1'    \/>\n\t\t\t\t<label for='choice_3_19_1' id='label_3_19_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_20\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\"><label class='gfield_label gform-field-label' for='input_3_20' >If yes, how many cigarettes per day BEFORE the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_3_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_24\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_24\"><label class='gfield_label gform-field-label' for='input_3_24' >If yes, how many cigarettes per day DURING the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_22\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_22\"><label class='gfield_label gform-field-label'  >Do you drink alcohol?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_22'>\n\t\t\t<li class='gchoice gchoice_3_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='No'  id='choice_3_22_0'    \/>\n\t\t\t\t<label for='choice_3_22_0' id='label_3_22_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Yes'  id='choice_3_22_1'    \/>\n\t\t\t\t<label for='choice_3_22_1' id='label_3_22_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_23\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_23\"><label class='gfield_label gform-field-label' for='input_3_23' >If yes, how many units per day BEFORE the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_23\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_23'>1 glass of wine = 3 units.  1 beer = 1 unit. <\/div><\/li><li id=\"field_3_21\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\"><label class='gfield_label gform-field-label' for='input_3_21' >If yes, how many units per day DURING the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_21\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_21'>1 beer = 1 unit.   \n1 glass of wine = 3 units<\/div><\/li><li id=\"field_3_25\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_25\"><label class='gfield_label gform-field-label'  >Do you use drugs?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_25'>\n\t\t\t<li class='gchoice gchoice_3_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='No'  id='choice_3_25_0'    \/>\n\t\t\t\t<label for='choice_3_25_0' id='label_3_25_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Yes'  id='choice_3_25_1'    \/>\n\t\t\t\t<label for='choice_3_25_1' id='label_3_25_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_26\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_26\"><label class='gfield_label gform-field-label' for='input_3_26' >If yes, what drugs do you use?<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_3_26' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_27\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_27\"><label class='gfield_label gform-field-label' for='input_3_27' >If yes, how often per week BEFORE the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_3_27' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_28\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_28\"><label class='gfield_label gform-field-label' for='input_3_28' >If yes, how often per week DURING the pregnancy?<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_3_28' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_29\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_29\"><label class='gfield_label gform-field-label'  >Do you take any medication?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_29'>\n\t\t\t<li class='gchoice gchoice_3_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='No'  id='choice_3_29_0'    \/>\n\t\t\t\t<label for='choice_3_29_0' id='label_3_29_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='Yes'  id='choice_3_29_1'    \/>\n\t\t\t\t<label for='choice_3_29_1' id='label_3_29_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_30\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_30\"><label class='gfield_label gform-field-label' for='input_3_30' >If yes, what medication do you take?<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_3_30' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_31\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_31\"><label class='gfield_label gform-field-label' for='input_3_31' >Since when?<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_3_31' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_32\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_32\"><label class='gfield_label gform-field-label' for='input_3_32' >What is the dosage?<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_3_32' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_33\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_33\"><label class='gfield_label gform-field-label'  >Do you eat fresh fruit and vegetables every day?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_33'>\n\t\t\t<li class='gchoice gchoice_3_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Yes'  id='choice_3_33_0'    \/>\n\t\t\t\t<label for='choice_3_33_0' id='label_3_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='No'  id='choice_3_33_1'    \/>\n\t\t\t\t<label for='choice_3_33_1' id='label_3_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_36\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_36\"><label class='gfield_label gform-field-label'  >Do you follow a special diet?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_36'>\n\t\t\t<li class='gchoice gchoice_3_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_3_36_0'    \/>\n\t\t\t\t<label for='choice_3_36_0' id='label_3_36_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='Vegetarian'  id='choice_3_36_1'    \/>\n\t\t\t\t<label for='choice_3_36_1' id='label_3_36_1' class='gform-field-label gform-field-label--type-inline'>Vegetarian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_36_2'>\n\t\t\t\t<input name='input_36' type='radio' value='Vegan'  id='choice_3_36_2'    \/>\n\t\t\t\t<label for='choice_3_36_2' id='label_3_36_2' class='gform-field-label gform-field-label--type-inline'>Vegan<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_36_3'>\n\t\t\t\t<input name='input_36' type='radio' value='Macrobiotic'  id='choice_3_36_3'    \/>\n\t\t\t\t<label for='choice_3_36_3' id='label_3_36_3' class='gform-field-label gform-field-label--type-inline'>Macrobiotic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_36_4'>\n\t\t\t\t<input name='input_36' type='radio' value='gf_other_choice'  id='choice_3_36_4'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_3_36_other' name='input_36_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_41\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_41\"><label class='gfield_label gform-field-label'  >Are you in good health?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_41'>\n\t\t\t<li class='gchoice gchoice_3_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Yes'  id='choice_3_41_0'    \/>\n\t\t\t\t<label for='choice_3_41_0' id='label_3_41_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='No'  id='choice_3_41_1'    \/>\n\t\t\t\t<label for='choice_3_41_1' id='label_3_41_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_37\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_37\"><label class='gfield_label gform-field-label'  >Have you been vaccinated against Rubella?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_37'>\n\t\t\t<li class='gchoice gchoice_3_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Yes'  id='choice_3_37_0'    \/>\n\t\t\t\t<label for='choice_3_37_0' id='label_3_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='No'  id='choice_3_37_1'    \/>\n\t\t\t\t<label for='choice_3_37_1' id='label_3_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_37'>(German measles)<\/div><\/li><li id=\"field_3_38\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_38\"><label class='gfield_label gform-field-label'  >Have you had Chicken Pox or been vaccinated against Chicken Pox?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_38'>\n\t\t\t<li class='gchoice gchoice_3_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Yes'  id='choice_3_38_0'    \/>\n\t\t\t\t<label for='choice_3_38_0' id='label_3_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='No'  id='choice_3_38_1'    \/>\n\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_38'>(Varicella)<\/div><\/li><li id=\"field_3_39\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_39\"><label class='gfield_label gform-field-label'  >Have you ever had a blood transfusion?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_39'>\n\t\t\t<li class='gchoice gchoice_3_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='No'  id='choice_3_39_0'    \/>\n\t\t\t\t<label for='choice_3_39_0' id='label_3_39_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='Yes'  id='choice_3_39_1'    \/>\n\t\t\t\t<label for='choice_3_39_1' id='label_3_39_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_40\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_40\"><label class='gfield_label gform-field-label'  >Have you been treated in or admitted to a hospital in a foreign country within the last two months?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_40'>\n\t\t\t<li class='gchoice gchoice_3_40_0'>\n\t\t\t\t<input name='input_40' type='radio' value='No'  id='choice_3_40_0'    \/>\n\t\t\t\t<label for='choice_3_40_0' id='label_3_40_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_40_1'>\n\t\t\t\t<input name='input_40' type='radio' value='Yes'  id='choice_3_40_1'    \/>\n\t\t\t\t<label for='choice_3_40_1' id='label_3_40_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_42\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_42\"><h2 class=\"gsection_title\">Are you suffering from or have you ever suffered from any of the following medical conditions?<\/h2><\/li><li id=\"field_3_43\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_43\"><label class='gfield_label gform-field-label'  >Cystitis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_43'>\n\t\t\t<li class='gchoice gchoice_3_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='No'  id='choice_3_43_0'    \/>\n\t\t\t\t<label for='choice_3_43_0' id='label_3_43_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes'  id='choice_3_43_1'    \/>\n\t\t\t\t<label for='choice_3_43_1' id='label_3_43_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_43'>Urine infection<\/div><\/li><li id=\"field_3_44\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_44\"><label class='gfield_label gform-field-label'  >If yes, how often?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_44'>\n\t\t\t<li class='gchoice gchoice_3_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Sporadic'  id='choice_3_44_0'    \/>\n\t\t\t\t<label for='choice_3_44_0' id='label_3_44_0' class='gform-field-label gform-field-label--type-inline'>Sporadic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='1-2 x per year'  id='choice_3_44_1'    \/>\n\t\t\t\t<label for='choice_3_44_1' id='label_3_44_1' class='gform-field-label gform-field-label--type-inline'>1-2 x per year<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_44_2'>\n\t\t\t\t<input name='input_44' type='radio' value='More than 2 x per year'  id='choice_3_44_2'    \/>\n\t\t\t\t<label for='choice_3_44_2' id='label_3_44_2' class='gform-field-label gform-field-label--type-inline'>More than 2 x per year<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_45\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_45\"><label class='gfield_label gform-field-label'  >Candida<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_45'>\n\t\t\t<li class='gchoice gchoice_3_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_3_45_0'    \/>\n\t\t\t\t<label for='choice_3_45_0' id='label_3_45_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_3_45_1'    \/>\n\t\t\t\t<label for='choice_3_45_1' id='label_3_45_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_45'>Vaginal yeast infection<\/div><\/li><li id=\"field_3_46\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_46\"><label class='gfield_label gform-field-label'  >If yes, how often?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_46'>\n\t\t\t<li class='gchoice gchoice_3_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Sporadic'  id='choice_3_46_0'    \/>\n\t\t\t\t<label for='choice_3_46_0' id='label_3_46_0' class='gform-field-label gform-field-label--type-inline'>Sporadic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='1-2 x per year'  id='choice_3_46_1'    \/>\n\t\t\t\t<label for='choice_3_46_1' id='label_3_46_1' class='gform-field-label gform-field-label--type-inline'>1-2 x per year<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='More than 2 x per year'  id='choice_3_46_2'    \/>\n\t\t\t\t<label for='choice_3_46_2' id='label_3_46_2' class='gform-field-label gform-field-label--type-inline'>More than 2 x per year<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_47\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\"><label class='gfield_label gform-field-label'  >Infection in gums<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_47'>\n\t\t\t<li class='gchoice gchoice_3_47_0'>\n\t\t\t\t<input name='input_47' type='radio' value='No'  id='choice_3_47_0'    \/>\n\t\t\t\t<label for='choice_3_47_0' id='label_3_47_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_47_1'>\n\t\t\t\t<input name='input_47' type='radio' value='Yes'  id='choice_3_47_1'    \/>\n\t\t\t\t<label for='choice_3_47_1' id='label_3_47_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_47'>Gingivitis<\/div><\/li><li id=\"field_3_48\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_48\"><label class='gfield_label gform-field-label'  >Allergies<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_48'>\n\t\t\t<li class='gchoice gchoice_3_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_3_48_0'    \/>\n\t\t\t\t<label for='choice_3_48_0' id='label_3_48_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_3_48_1'    \/>\n\t\t\t\t<label for='choice_3_48_1' id='label_3_48_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_49\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_49\"><label class='gfield_label gform-field-label' for='input_3_49' >If yes, what allergies to you have?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_49' id='input_3_49' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_50\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\"><label class='gfield_label gform-field-label'  >Cold sores<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_50'>\n\t\t\t<li class='gchoice gchoice_3_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_3_50_0'    \/>\n\t\t\t\t<label for='choice_3_50_0' id='label_3_50_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_3_50_1'    \/>\n\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_51\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\"><label class='gfield_label gform-field-label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_51'>\n\t\t\t<li class='gchoice gchoice_3_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='No'  id='choice_3_51_0'    \/>\n\t\t\t\t<label for='choice_3_51_0' id='label_3_51_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='Yes'  id='choice_3_51_1'    \/>\n\t\t\t\t<label for='choice_3_51_1' id='label_3_51_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_52\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_52\"><label class='gfield_label gform-field-label'  >Thrombosis<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_52'>\n\t\t\t<li class='gchoice gchoice_3_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_3_52_0'    \/>\n\t\t\t\t<label for='choice_3_52_0' id='label_3_52_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_3_52_1'    \/>\n\t\t\t\t<label for='choice_3_52_1' id='label_3_52_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_53\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_53\"><label class='gfield_label gform-field-label'  >Do you bruise easily or do wounds take a long time to stop bleeding?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_53'>\n\t\t\t<li class='gchoice gchoice_3_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_3_53_0'    \/>\n\t\t\t\t<label for='choice_3_53_0' id='label_3_53_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_3_53_1'    \/>\n\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_54\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_54\"><label class='gfield_label gform-field-label'  >Cardio-vascular disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_54'>\n\t\t\t<li class='gchoice gchoice_3_54_0'>\n\t\t\t\t<input name='input_54' type='radio' value='No'  id='choice_3_54_0'    \/>\n\t\t\t\t<label for='choice_3_54_0' id='label_3_54_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_54_1'>\n\t\t\t\t<input name='input_54' type='radio' value='Yes'  id='choice_3_54_1'    \/>\n\t\t\t\t<label for='choice_3_54_1' id='label_3_54_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_54'>Heart and circulatory problems<\/div><\/li><li id=\"field_3_55\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_55\"><label class='gfield_label gform-field-label'  >Liver or kidney disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_55'>\n\t\t\t<li class='gchoice gchoice_3_55_0'>\n\t\t\t\t<input name='input_55' type='radio' value='No'  id='choice_3_55_0'    \/>\n\t\t\t\t<label for='choice_3_55_0' id='label_3_55_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_55_1'>\n\t\t\t\t<input name='input_55' type='radio' value='Yes'  id='choice_3_55_1'    \/>\n\t\t\t\t<label for='choice_3_55_1' id='label_3_55_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_56\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_56\"><label class='gfield_label gform-field-label'  >Epilepsy<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_56'>\n\t\t\t<li class='gchoice gchoice_3_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_3_56_0'    \/>\n\t\t\t\t<label for='choice_3_56_0' id='label_3_56_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_3_56_1'    \/>\n\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_57\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_57\"><label class='gfield_label gform-field-label'  >Cancer<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_57'>\n\t\t\t<li class='gchoice gchoice_3_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='No'  id='choice_3_57_0'    \/>\n\t\t\t\t<label for='choice_3_57_0' id='label_3_57_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Yes'  id='choice_3_57_1'    \/>\n\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_58\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_58\"><label class='gfield_label gform-field-label'  >Asthma\/chronic bronchitis (COPD)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_58'>\n\t\t\t<li class='gchoice gchoice_3_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='No'  id='choice_3_58_0'    \/>\n\t\t\t\t<label for='choice_3_58_0' id='label_3_58_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Yes'  id='choice_3_58_1'    \/>\n\t\t\t\t<label for='choice_3_58_1' id='label_3_58_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_59\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_59\"><label class='gfield_label gform-field-label'  >Rheumatism<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_59'>\n\t\t\t<li class='gchoice gchoice_3_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_3_59_0'    \/>\n\t\t\t\t<label for='choice_3_59_0' id='label_3_59_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_3_59_1'    \/>\n\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_60\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_60\"><label class='gfield_label gform-field-label'  >Eating disorders<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_60'>\n\t\t\t<li class='gchoice gchoice_3_60_0'>\n\t\t\t\t<input name='input_60' type='radio' value='No'  id='choice_3_60_0'    \/>\n\t\t\t\t<label for='choice_3_60_0' id='label_3_60_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_60_1'>\n\t\t\t\t<input name='input_60' type='radio' value='Yes'  id='choice_3_60_1'    \/>\n\t\t\t\t<label for='choice_3_60_1' id='label_3_60_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_61\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_61\"><label class='gfield_label gform-field-label'  >Are you being (or have been) treated by a medical specialist?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_61'>\n\t\t\t<li class='gchoice gchoice_3_61_0'>\n\t\t\t\t<input name='input_61' type='radio' value='No'  id='choice_3_61_0'    \/>\n\t\t\t\t<label for='choice_3_61_0' id='label_3_61_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_61_1'>\n\t\t\t\t<input name='input_61' type='radio' value='Yes'  id='choice_3_61_1'    \/>\n\t\t\t\t<label for='choice_3_61_1' id='label_3_61_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_61'>Hospital consultant<\/div><\/li><li id=\"field_3_62\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\"><label class='gfield_label gform-field-label' for='input_3_62' >If yes, which specialist?<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_3_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_63\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_63\"><label class='gfield_label gform-field-label' for='input_3_63' >If yes, which hospital?<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_3_63' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_64\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_64\"><label class='gfield_label gform-field-label' for='input_3_64' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_3_64' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_64\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_64'>Month-Year<\/div><\/li><li id=\"field_3_65\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_65\"><label class='gfield_label gform-field-label' for='input_3_65' >What are\/were you being treated for?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_65' id='input_3_65' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_66\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_66\"><label class='gfield_label gform-field-label'  >Have you every had any surgery?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_66'>\n\t\t\t<li class='gchoice gchoice_3_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='No'  id='choice_3_66_0'    \/>\n\t\t\t\t<label for='choice_3_66_0' id='label_3_66_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Yes'  id='choice_3_66_1'    \/>\n\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_67\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_67\"><label class='gfield_label gform-field-label' for='input_3_67' >If yes, which specialist carried out the surgery?<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_3_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_68\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_68\"><label class='gfield_label gform-field-label' for='input_3_68' >In which hospital?<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_3_68' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_69\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_69\"><label class='gfield_label gform-field-label' for='input_3_69' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_3_69' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_70\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\"><label class='gfield_label gform-field-label' for='input_3_70' >What type of surgery?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_3_70' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_71\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_71\"><label class='gfield_label gform-field-label' for='input_3_71' >Please detail any further procedures\/surgeries?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_71' id='input_3_71' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_72\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\"><label class='gfield_label gform-field-label'  >Are you related to the father of the baby?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_72'>\n\t\t\t<li class='gchoice gchoice_3_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_3_72_0'    \/>\n\t\t\t\t<label for='choice_3_72_0' id='label_3_72_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Yes'  id='choice_3_72_1'    \/>\n\t\t\t\t<label for='choice_3_72_1' id='label_3_72_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_72'>Blood relation<\/div><\/li><li id=\"field_3_73\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_73\"><label class='gfield_label gform-field-label' for='input_3_73' >If yes, please explain how you are related:<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_3_73' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_74\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_74\"><label class='gfield_label gform-field-label'  >Do you have any hereditary disease(s)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_74'>\n\t\t\t<li class='gchoice gchoice_3_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='No'  id='choice_3_74_0'    \/>\n\t\t\t\t<label for='choice_3_74_0' id='label_3_74_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='Yes'  id='choice_3_74_1'    \/>\n\t\t\t\t<label for='choice_3_74_1' id='label_3_74_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_75\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\"><label class='gfield_label gform-field-label' for='input_3_75' >If yes, please provide details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_3_75' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_76\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_76\"><h2 class=\"gsection_title\">Psycho-social care<\/h2><\/li><li id=\"field_3_77\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_77\"><label class='gfield_label gform-field-label'  >Have you ever had contact with:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_77'>\n\t\t\t<li class='gchoice gchoice_3_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='A social worker'  id='choice_3_77_0'    \/>\n\t\t\t\t<label for='choice_3_77_0' id='label_3_77_0' class='gform-field-label gform-field-label--type-inline'>A social worker<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='A psychologist'  id='choice_3_77_1'    \/>\n\t\t\t\t<label for='choice_3_77_1' id='label_3_77_1' class='gform-field-label gform-field-label--type-inline'>A psychologist<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_77_2'>\n\t\t\t\t<input name='input_77' type='radio' value='A psychiatrist'  id='choice_3_77_2'    \/>\n\t\t\t\t<label for='choice_3_77_2' id='label_3_77_2' class='gform-field-label gform-field-label--type-inline'>A psychiatrist<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_77_3'>\n\t\t\t\t<input name='input_77' type='radio' value='Child support services'  id='choice_3_77_3'    \/>\n\t\t\t\t<label for='choice_3_77_3' id='label_3_77_3' class='gform-field-label gform-field-label--type-inline'>Child support services<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_78\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_78\"><label class='gfield_label gform-field-label' for='input_3_78' >If yes, when?<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_3_78' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_79\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_79\"><label class='gfield_label gform-field-label' for='input_3_79' >If yes, what was the reason?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_3_79' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_80\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_80\"><label class='gfield_label gform-field-label'  >Have you every used psychiatric medication?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_80'>\n\t\t\t<li class='gchoice gchoice_3_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='No'  id='choice_3_80_0'    \/>\n\t\t\t\t<label for='choice_3_80_0' id='label_3_80_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='Yes'  id='choice_3_80_1'    \/>\n\t\t\t\t<label for='choice_3_80_1' id='label_3_80_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_81\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_81\"><label class='gfield_label gform-field-label' for='input_3_81' >If yes, which medication?<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_3_81' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_82\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_82\"><label class='gfield_label gform-field-label' for='input_3_82' >When?<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_3_82' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_83\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_83\"><label class='gfield_label gform-field-label' for='input_3_83' >For how long?<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_3_83' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_84\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_84\"><label class='gfield_label gform-field-label'  >Do you have enough support around you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_84'>\n\t\t\t<li class='gchoice gchoice_3_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Yes'  id='choice_3_84_0'    \/>\n\t\t\t\t<label for='choice_3_84_0' id='label_3_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='No'  id='choice_3_84_1'    \/>\n\t\t\t\t<label for='choice_3_84_1' id='label_3_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_85\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_85\"><label class='gfield_label gform-field-label'  >Have you ever been abused?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_85'>\n\t\t\t<li class='gchoice gchoice_3_85_0'>\n\t\t\t\t<input name='input_85' type='radio' value='No'  id='choice_3_85_0'    \/>\n\t\t\t\t<label for='choice_3_85_0' id='label_3_85_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_85_1'>\n\t\t\t\t<input name='input_85' type='radio' value='Yes'  id='choice_3_85_1'    \/>\n\t\t\t\t<label for='choice_3_85_1' id='label_3_85_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_86\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_86\"><label class='gfield_label gform-field-label'  >Have you ever been a witness of abuse?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_86'>\n\t\t\t<li class='gchoice gchoice_3_86_0'>\n\t\t\t\t<input name='input_86' type='radio' value='No'  id='choice_3_86_0'    \/>\n\t\t\t\t<label for='choice_3_86_0' id='label_3_86_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_86_1'>\n\t\t\t\t<input name='input_86' type='radio' value='Yes'  id='choice_3_86_1'    \/>\n\t\t\t\t<label for='choice_3_86_1' id='label_3_86_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_87\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_87\"><label class='gfield_label gform-field-label'  >Have you ever been a victim of sexual abuse?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_87'>\n\t\t\t<li class='gchoice gchoice_3_87_0'>\n\t\t\t\t<input name='input_87' type='radio' value='No'  id='choice_3_87_0'    \/>\n\t\t\t\t<label for='choice_3_87_0' id='label_3_87_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_87_1'>\n\t\t\t\t<input name='input_87' type='radio' value='Yes'  id='choice_3_87_1'    \/>\n\t\t\t\t<label for='choice_3_87_1' id='label_3_87_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_88\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_88\"><label class='gfield_label gform-field-label'  >Have you had a negative experience with a health care worker\/carer?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_88'>\n\t\t\t<li class='gchoice gchoice_3_88_0'>\n\t\t\t\t<input name='input_88' type='radio' value='No'  id='choice_3_88_0'    \/>\n\t\t\t\t<label for='choice_3_88_0' id='label_3_88_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_88_1'>\n\t\t\t\t<input name='input_88' type='radio' value='Yes'  id='choice_3_88_1'    \/>\n\t\t\t\t<label for='choice_3_88_1' id='label_3_88_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_89\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_89\"><h2 class=\"gsection_title\">Family history<\/h2><\/li><li id=\"field_3_90\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_90\"><label class='gfield_label gform-field-label'  >Is your partner in good health?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_90'>\n\t\t\t<li class='gchoice gchoice_3_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_3_90_0'    \/>\n\t\t\t\t<label for='choice_3_90_0' id='label_3_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='No'  id='choice_3_90_1'    \/>\n\t\t\t\t<label for='choice_3_90_1' id='label_3_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_91\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_91\"><label class='gfield_label gform-field-label' for='input_3_91' >If no, please provide further details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_3_91' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_92\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_92\"><label class='gfield_label gform-field-label'  >Does your partner smoke?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_92'>\n\t\t\t<li class='gchoice gchoice_3_92_0'>\n\t\t\t\t<input name='input_92' type='radio' value='No'  id='choice_3_92_0'    \/>\n\t\t\t\t<label for='choice_3_92_0' id='label_3_92_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_92_1'>\n\t\t\t\t<input name='input_92' type='radio' value='Yes'  id='choice_3_92_1'    \/>\n\t\t\t\t<label for='choice_3_92_1' id='label_3_92_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_93\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_93\"><label class='gfield_label gform-field-label'  >If yes, does your partner smoke in the house?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_93'>\n\t\t\t<li class='gchoice gchoice_3_93_0'>\n\t\t\t\t<input name='input_93' type='radio' value='No'  id='choice_3_93_0'    \/>\n\t\t\t\t<label for='choice_3_93_0' id='label_3_93_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_93_1'>\n\t\t\t\t<input name='input_93' type='radio' value='Yes'  id='choice_3_93_1'    \/>\n\t\t\t\t<label for='choice_3_93_1' id='label_3_93_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_94\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_94\"><label class='gfield_label gform-field-label'  >Does your partner ever suffer from cold sores?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_94'>\n\t\t\t<li class='gchoice gchoice_3_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='No'  id='choice_3_94_0'    \/>\n\t\t\t\t<label for='choice_3_94_0' id='label_3_94_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='Yes'  id='choice_3_94_1'    \/>\n\t\t\t\t<label for='choice_3_94_1' id='label_3_94_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_95\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_95\"><label class='gfield_label gform-field-label'  >Does your partner have a hereditary disease?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_95'>\n\t\t\t<li class='gchoice gchoice_3_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='No'  id='choice_3_95_0'    \/>\n\t\t\t\t<label for='choice_3_95_0' id='label_3_95_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Yes'  id='choice_3_95_1'    \/>\n\t\t\t\t<label for='choice_3_95_1' id='label_3_95_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_96\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_96\"><label class='gfield_label gform-field-label' for='input_3_96' >If yes, please provide further details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_96' id='input_3_96' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_97\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_97\"><h2 class=\"gsection_title\">Does anyone in your family or in your partner&#039;s family suffer from  any of the following diseases:<\/h2><\/li><li id=\"field_3_98\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_98\"><label class='gfield_label gform-field-label'  >High blood pressure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_98'>\n\t\t\t<li class='gchoice gchoice_3_98_0'>\n\t\t\t\t<input name='input_98' type='radio' value='No'  id='choice_3_98_0'    \/>\n\t\t\t\t<label for='choice_3_98_0' id='label_3_98_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_98_1'>\n\t\t\t\t<input name='input_98' type='radio' value='Yes'  id='choice_3_98_1'    \/>\n\t\t\t\t<label for='choice_3_98_1' id='label_3_98_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_99\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_99\"><label class='gfield_label gform-field-label' for='input_3_99' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_3_99' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_100\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_100\"><label class='gfield_label gform-field-label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_100'>\n\t\t\t<li class='gchoice gchoice_3_100_0'>\n\t\t\t\t<input name='input_100' type='radio' value='No'  id='choice_3_100_0'    \/>\n\t\t\t\t<label for='choice_3_100_0' id='label_3_100_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_100_1'>\n\t\t\t\t<input name='input_100' type='radio' value='Yes'  id='choice_3_100_1'    \/>\n\t\t\t\t<label for='choice_3_100_1' id='label_3_100_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_101\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_101\"><label class='gfield_label gform-field-label' for='input_3_101' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_3_101' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_102\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_102\"><label class='gfield_label gform-field-label'  >Hereditary anaemia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_102'>\n\t\t\t<li class='gchoice gchoice_3_102_0'>\n\t\t\t\t<input name='input_102' type='radio' value='No'  id='choice_3_102_0'    \/>\n\t\t\t\t<label for='choice_3_102_0' id='label_3_102_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_102_1'>\n\t\t\t\t<input name='input_102' type='radio' value='Yes'  id='choice_3_102_1'    \/>\n\t\t\t\t<label for='choice_3_102_1' id='label_3_102_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_102'>Thalassemia\/Sickle-cell disease<\/div><\/li><li id=\"field_3_103\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_103\"><label class='gfield_label gform-field-label' for='input_3_103' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_3_103' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_104\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_104\"><label class='gfield_label gform-field-label'  >Clotting disorder\/haemophilia<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_104'>\n\t\t\t<li class='gchoice gchoice_3_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='No'  id='choice_3_104_0'    \/>\n\t\t\t\t<label for='choice_3_104_0' id='label_3_104_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='Yes'  id='choice_3_104_1'    \/>\n\t\t\t\t<label for='choice_3_104_1' id='label_3_104_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_105\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_105\"><label class='gfield_label gform-field-label' for='input_3_105' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_3_105' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_106\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_106\"><label class='gfield_label gform-field-label'  >Congenital blindness or poor vision<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_106'>\n\t\t\t<li class='gchoice gchoice_3_106_0'>\n\t\t\t\t<input name='input_106' type='radio' value='No'  id='choice_3_106_0'    \/>\n\t\t\t\t<label for='choice_3_106_0' id='label_3_106_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_106_1'>\n\t\t\t\t<input name='input_106' type='radio' value='Yes'  id='choice_3_106_1'    \/>\n\t\t\t\t<label for='choice_3_106_1' id='label_3_106_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_107\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_107\"><label class='gfield_label gform-field-label' for='input_3_107' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_3_107' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_108\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_108\"><label class='gfield_label gform-field-label'  >Congenital deafness<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_108'>\n\t\t\t<li class='gchoice gchoice_3_108_0'>\n\t\t\t\t<input name='input_108' type='radio' value='No'  id='choice_3_108_0'    \/>\n\t\t\t\t<label for='choice_3_108_0' id='label_3_108_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_108_1'>\n\t\t\t\t<input name='input_108' type='radio' value='Yes'  id='choice_3_108_1'    \/>\n\t\t\t\t<label for='choice_3_108_1' id='label_3_108_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_109\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_109\"><label class='gfield_label gform-field-label' for='input_3_109' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_3_109' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_110\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_110\"><label class='gfield_label gform-field-label'  >Heart defects<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_110'>\n\t\t\t<li class='gchoice gchoice_3_110_0'>\n\t\t\t\t<input name='input_110' type='radio' value='No'  id='choice_3_110_0'    \/>\n\t\t\t\t<label for='choice_3_110_0' id='label_3_110_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_110_1'>\n\t\t\t\t<input name='input_110' type='radio' value='Yes'  id='choice_3_110_1'    \/>\n\t\t\t\t<label for='choice_3_110_1' id='label_3_110_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_111\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_111\"><label class='gfield_label gform-field-label' for='input_3_111' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_111' id='input_3_111' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_112\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_112\"><label class='gfield_label gform-field-label'  >Diseases of the central nervous system<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_112'>\n\t\t\t<li class='gchoice gchoice_3_112_0'>\n\t\t\t\t<input name='input_112' type='radio' value='No'  id='choice_3_112_0'    \/>\n\t\t\t\t<label for='choice_3_112_0' id='label_3_112_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_112_1'>\n\t\t\t\t<input name='input_112' type='radio' value='Yes'  id='choice_3_112_1'    \/>\n\t\t\t\t<label for='choice_3_112_1' id='label_3_112_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_113\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_113\"><label class='gfield_label gform-field-label' for='input_3_113' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_3_113' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_115\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_115\"><label class='gfield_label gform-field-label'  >Hip defects<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_115'>\n\t\t\t<li class='gchoice gchoice_3_115_0'>\n\t\t\t\t<input name='input_115' type='radio' value='No'  id='choice_3_115_0'    \/>\n\t\t\t\t<label for='choice_3_115_0' id='label_3_115_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_115_1'>\n\t\t\t\t<input name='input_115' type='radio' value='Yes'  id='choice_3_115_1'    \/>\n\t\t\t\t<label for='choice_3_115_1' id='label_3_115_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_114\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_114\"><label class='gfield_label gform-field-label' for='input_3_114' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_3_114' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_116\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_116\"><label class='gfield_label gform-field-label'  >Muscular diseases<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_116'>\n\t\t\t<li class='gchoice gchoice_3_116_0'>\n\t\t\t\t<input name='input_116' type='radio' value='No'  id='choice_3_116_0'    \/>\n\t\t\t\t<label for='choice_3_116_0' id='label_3_116_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_116_1'>\n\t\t\t\t<input name='input_116' type='radio' value='Yes'  id='choice_3_116_1'    \/>\n\t\t\t\t<label for='choice_3_116_1' id='label_3_116_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_117\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_117\"><label class='gfield_label gform-field-label' for='input_3_117' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_3_117' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_118\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_118\"><label class='gfield_label gform-field-label'  >Cleft lip or cleft palate?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_118'>\n\t\t\t<li class='gchoice gchoice_3_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='No'  id='choice_3_118_0'    \/>\n\t\t\t\t<label for='choice_3_118_0' id='label_3_118_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='Yes'  id='choice_3_118_1'    \/>\n\t\t\t\t<label for='choice_3_118_1' id='label_3_118_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_118'>Schisis<\/div><\/li><li id=\"field_3_119\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_119\"><label class='gfield_label gform-field-label' for='input_3_119' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_3_119' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_120\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_120\"><label class='gfield_label gform-field-label'  >Spina bifida, anencephaly or hydrocephaly?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_120'>\n\t\t\t<li class='gchoice gchoice_3_120_0'>\n\t\t\t\t<input name='input_120' type='radio' value='No'  id='choice_3_120_0'    \/>\n\t\t\t\t<label for='choice_3_120_0' id='label_3_120_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_120_1'>\n\t\t\t\t<input name='input_120' type='radio' value='Yes'  id='choice_3_120_1'    \/>\n\t\t\t\t<label for='choice_3_120_1' id='label_3_120_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_121\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_121\"><label class='gfield_label gform-field-label' for='input_3_121' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_3_121' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_122\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_122\"><label class='gfield_label gform-field-label'  >Down&#039;s Syndrome<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_122'>\n\t\t\t<li class='gchoice gchoice_3_122_0'>\n\t\t\t\t<input name='input_122' type='radio' value='No'  id='choice_3_122_0'    \/>\n\t\t\t\t<label for='choice_3_122_0' id='label_3_122_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_122_1'>\n\t\t\t\t<input name='input_122' type='radio' value='Yes'  id='choice_3_122_1'    \/>\n\t\t\t\t<label for='choice_3_122_1' id='label_3_122_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_123\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_123\"><label class='gfield_label gform-field-label' for='input_3_123' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_3_123' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_124\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_124\"><label class='gfield_label gform-field-label'  >Mental retardation (eg. Fragile X syndrome)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_124'>\n\t\t\t<li class='gchoice gchoice_3_124_0'>\n\t\t\t\t<input name='input_124' type='radio' value='No'  id='choice_3_124_0'    \/>\n\t\t\t\t<label for='choice_3_124_0' id='label_3_124_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_124_1'>\n\t\t\t\t<input name='input_124' type='radio' value='Yes'  id='choice_3_124_1'    \/>\n\t\t\t\t<label for='choice_3_124_1' id='label_3_124_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_125\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_125\"><label class='gfield_label gform-field-label' for='input_3_125' >If yes, by whom?<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_3_125' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_126\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_126\"><label class='gfield_label gform-field-label'  >Any other hereditary or congenital defects?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_126'>\n\t\t\t<li class='gchoice gchoice_3_126_0'>\n\t\t\t\t<input name='input_126' type='radio' value='No'  id='choice_3_126_0'    \/>\n\t\t\t\t<label for='choice_3_126_0' id='label_3_126_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_126_1'>\n\t\t\t\t<input name='input_126' type='radio' value='Yes'  id='choice_3_126_1'    \/>\n\t\t\t\t<label for='choice_3_126_1' id='label_3_126_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_128\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_128\"><label class='gfield_label gform-field-label' for='input_3_128' >If yes, please provide details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_3_128' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_129\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_129\"><h2 class=\"gsection_title\">Finances<\/h2><\/li><li id=\"field_3_130\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_130\"><label class='gfield_label gform-field-label'  >Do you and\/or your partner combined earn less than \u20ac2000 per month?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_130'>\n\t\t\t<li class='gchoice gchoice_3_130_0'>\n\t\t\t\t<input name='input_130' type='radio' value='No'  id='choice_3_130_0'    \/>\n\t\t\t\t<label for='choice_3_130_0' id='label_3_130_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_130_1'>\n\t\t\t\t<input name='input_130' type='radio' value='Yes'  id='choice_3_130_1'    \/>\n\t\t\t\t<label for='choice_3_130_1' id='label_3_130_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_131\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_131\"><label class='gfield_label gform-field-label'  >Are you experiencing financial difficulties?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_131'>\n\t\t\t<li class='gchoice gchoice_3_131_0'>\n\t\t\t\t<input name='input_131' type='radio' value='No'  id='choice_3_131_0'    \/>\n\t\t\t\t<label for='choice_3_131_0' id='label_3_131_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_131_1'>\n\t\t\t\t<input name='input_131' type='radio' value='Yes'  id='choice_3_131_1'    \/>\n\t\t\t\t<label for='choice_3_131_1' id='label_3_131_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_132\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_132\"><label class='gfield_label gform-field-label'  >If yes, do you have help to deal with these difficulties?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_132'>\n\t\t\t<li class='gchoice gchoice_3_132_0'>\n\t\t\t\t<input name='input_132' type='radio' value='No'  id='choice_3_132_0'    \/>\n\t\t\t\t<label for='choice_3_132_0' id='label_3_132_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_132_1'>\n\t\t\t\t<input name='input_132' type='radio' value='Yes'  id='choice_3_132_1'    \/>\n\t\t\t\t<label for='choice_3_132_1' id='label_3_132_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_132_2'>\n\t\t\t\t<input name='input_132' type='radio' value='n\/a'  id='choice_3_132_2'    \/>\n\t\t\t\t<label for='choice_3_132_2' id='label_3_132_2' class='gform-field-label gform-field-label--type-inline'>n\/a<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_133\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_133\"><h2 class=\"gsection_title\">Obstetric and gynaecological history<\/h2><\/li><li id=\"field_3_134\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_134\"><label class='gfield_label gform-field-label'  >Do you have children?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_134'>\n\t\t\t<li class='gchoice gchoice_3_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_3_134_0'    \/>\n\t\t\t\t<label for='choice_3_134_0' id='label_3_134_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='Yes'  id='choice_3_134_1'    \/>\n\t\t\t\t<label for='choice_3_134_1' id='label_3_134_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_170\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_170\"><h2 class=\"gsection_title\">If no, scroll to the next section<\/h2><\/li><li id=\"field_3_135\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_135\"><label class='gfield_label gform-field-label' for='input_3_135' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_135' id='input_3_135' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_3_135_date_format gfield_description_3_135\" aria-invalid=\"false\" \/>\n                            <span id='input_3_135_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_135' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_3_135'>1st child<\/div><\/li><li id=\"field_3_136\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_136\"><label class='gfield_label gform-field-label' for='input_3_136' >Where was he\/she born?<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_3_136' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_151\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_151\"><label class='gfield_label gform-field-label' for='input_3_151' >How far pregnant were you when you gave birth?<\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_3_151' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_151\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_151'>Weeks&#8230;days&#8230;(eg. 40 weeks, 3 days)<\/div><\/li><li id=\"field_3_138\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_138\"><label class='gfield_label gform-field-label'  >Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_138'>\n\t\t\t<li class='gchoice gchoice_3_138_0'>\n\t\t\t\t<input name='input_138' type='radio' value='Boy'  id='choice_3_138_0'    \/>\n\t\t\t\t<label for='choice_3_138_0' id='label_3_138_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_138_1'>\n\t\t\t\t<input name='input_138' type='radio' value='Girl'  id='choice_3_138_1'    \/>\n\t\t\t\t<label for='choice_3_138_1' id='label_3_138_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_139\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_139\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_139'>\n                            \n                            <span id='input_3_139_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.3' id='input_3_139_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_139_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_3_139_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.4' id='input_3_139_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_139_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_139_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.6' id='input_3_139_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_139_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_3_139'>1st child<\/div><\/li><li id=\"field_3_140\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_140\"><label class='gfield_label gform-field-label' for='input_3_140' >Birth weight<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_3_140' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_140\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_140'>1st child (grams)<\/div><\/li><li id=\"field_3_141\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_141\"><label class='gfield_label gform-field-label' for='input_3_141' >Type of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_3_141' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_141\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_141'>1st child <\/div><\/li><li id=\"field_3_142\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_142\"><label class='gfield_label gform-field-label' for='input_3_142' >Further details\/complications?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_142' id='input_3_142' class='textarea medium'  aria-describedby=\"gfield_description_3_142\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_142'>1st child <\/div><\/li><li id=\"field_3_143\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_143\"><label class='gfield_label gform-field-label' for='input_3_143' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_143' id='input_3_143' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_3_143_date_format gfield_description_3_143\" aria-invalid=\"false\" \/>\n                            <span id='input_3_143_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_143' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_3_143'>2nd child<\/div><\/li><li id=\"field_3_146\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_146\"><label class='gfield_label gform-field-label' for='input_3_146' >Where was he\/she born?<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_3_146' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_146\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_146'>2nd child<\/div><\/li><li id=\"field_3_150\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_150\"><label class='gfield_label gform-field-label' for='input_3_150' >How far pregnant were you when you gave birth?<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_3_150' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_150\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_150'>Weeks&#8230;days&#8230;(eg. 40 weeks, 3 days)<\/div><\/li><li id=\"field_3_154\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_154\"><label class='gfield_label gform-field-label'  >Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_154'>\n\t\t\t<li class='gchoice gchoice_3_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='Boy'  id='choice_3_154_0'    \/>\n\t\t\t\t<label for='choice_3_154_0' id='label_3_154_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='Girl'  id='choice_3_154_1'    \/>\n\t\t\t\t<label for='choice_3_154_1' id='label_3_154_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_154'>2nd child<\/div><\/li><li id=\"field_3_157\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_157\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_157'>\n                            \n                            <span id='input_3_157_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_157.3' id='input_3_157_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_157_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_3_157_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_157.4' id='input_3_157_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_157_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_157_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_157.6' id='input_3_157_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_157_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_3_157'>2nd child<\/div><\/li><li id=\"field_3_163\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_163\"><label class='gfield_label gform-field-label' for='input_3_163' >Birth weight<\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_3_163' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_163\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_163'>2nd child (grams)<\/div><\/li><li id=\"field_3_166\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_166\"><label class='gfield_label gform-field-label' for='input_3_166' >Type of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_3_166' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_166\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_166'>2nd child <\/div><\/li><li id=\"field_3_169\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_169\"><label class='gfield_label gform-field-label' for='input_3_169' >Further details\/complications?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_169' id='input_3_169' class='textarea medium'  aria-describedby=\"gfield_description_3_169\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_169'>2nd child <\/div><\/li><li id=\"field_3_145\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_145\"><label class='gfield_label gform-field-label' for='input_3_145' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_145' id='input_3_145' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_3_145_date_format gfield_description_3_145\" aria-invalid=\"false\" \/>\n                            <span id='input_3_145_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_145' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_3_145'>3rd child<\/div><\/li><li id=\"field_3_147\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_147\"><label class='gfield_label gform-field-label' for='input_3_147' >Where was he\/she born?<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_3_147' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_149\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_149\"><label class='gfield_label gform-field-label' for='input_3_149' >How far pregnant were you when you gave birth?<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_3_149' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_149\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_149'>Weeks&#8230;days&#8230;(eg. 40 weeks, 3 days)<\/div><\/li><li id=\"field_3_153\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_153\"><label class='gfield_label gform-field-label'  >Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_153'>\n\t\t\t<li class='gchoice gchoice_3_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='Boy'  id='choice_3_153_0'    \/>\n\t\t\t\t<label for='choice_3_153_0' id='label_3_153_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='Girl'  id='choice_3_153_1'    \/>\n\t\t\t\t<label for='choice_3_153_1' id='label_3_153_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_156\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_156\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_156'>\n                            \n                            <span id='input_3_156_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_156.3' id='input_3_156_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_156_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_3_156_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_156.4' id='input_3_156_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_156_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_156_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_156.6' id='input_3_156_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_156_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_3_156'>3rd child<\/div><\/li><li id=\"field_3_162\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_162\"><label class='gfield_label gform-field-label' for='input_3_162' >Birth weight<\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_3_162' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_162\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_162'>3rd child (grams)<\/div><\/li><li id=\"field_3_165\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_165\"><label class='gfield_label gform-field-label' for='input_3_165' >Type of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_3_165' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_165\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_165'>3rd child <\/div><\/li><li id=\"field_3_168\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_168\"><label class='gfield_label gform-field-label' for='input_3_168' >Further details\/complications?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_168' id='input_3_168' class='textarea medium'  aria-describedby=\"gfield_description_3_168\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_168'>3rd child <\/div><\/li><li id=\"field_3_144\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_144\"><label class='gfield_label gform-field-label' for='input_3_144' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_144' id='input_3_144' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_3_144_date_format gfield_description_3_144\" aria-invalid=\"false\" \/>\n                            <span id='input_3_144_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_144' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_3_144'>4th child<\/div><\/li><li id=\"field_3_148\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_148\"><label class='gfield_label gform-field-label' for='input_3_148' >Where was he\/she born?<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_3_148' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_137\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_137\"><label class='gfield_label gform-field-label' for='input_3_137' >How far pregnant were you when you gave birth?<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_3_137' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_137\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_137'>Weeks&#8230;days&#8230;(eg. 40 weeks, 3 days)<\/div><\/li><li id=\"field_3_152\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_152\"><label class='gfield_label gform-field-label'  >Sex<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_152'>\n\t\t\t<li class='gchoice gchoice_3_152_0'>\n\t\t\t\t<input name='input_152' type='radio' value='Boy'  id='choice_3_152_0'    \/>\n\t\t\t\t<label for='choice_3_152_0' id='label_3_152_0' class='gform-field-label gform-field-label--type-inline'>Boy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_152_1'>\n\t\t\t\t<input name='input_152' type='radio' value='Girl'  id='choice_3_152_1'    \/>\n\t\t\t\t<label for='choice_3_152_1' id='label_3_152_1' class='gform-field-label gform-field-label--type-inline'>Girl<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_155\"  class=\"gfield gfield--type-name field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_155\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_155'>\n                            \n                            <span id='input_3_155_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_155.3' id='input_3_155_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_155_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_3_155_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_155.4' id='input_3_155_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_155_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_155_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_155.6' id='input_3_155_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_3_155_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><div class='gfield_description' id='gfield_description_3_155'>4th child<\/div><\/li><li id=\"field_3_161\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_161\"><label class='gfield_label gform-field-label' for='input_3_161' >Birth weight<\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_3_161' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_161\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_161'>4th child (grams)<\/div><\/li><li id=\"field_3_164\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_164\"><label class='gfield_label gform-field-label' for='input_3_164' >Type of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_3_164' type='text' value='' class='medium'  aria-describedby=\"gfield_description_3_164\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_3_164'>4th child <\/div><\/li><li id=\"field_3_167\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_167\"><label class='gfield_label gform-field-label' for='input_3_167' >Further details\/complications?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_3_167' class='textarea medium'  aria-describedby=\"gfield_description_3_167\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_167'>4th child <\/div><\/li><li id=\"field_3_171\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_171\"><label class='gfield_label gform-field-label'  >Do you have a child with a congenital defect?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_171'>\n\t\t\t<li class='gchoice gchoice_3_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='No'  id='choice_3_171_0'    \/>\n\t\t\t\t<label for='choice_3_171_0' id='label_3_171_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='Yes'  id='choice_3_171_1'    \/>\n\t\t\t\t<label for='choice_3_171_1' id='label_3_171_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_172\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_172\"><label class='gfield_label gform-field-label' for='input_3_172' >If yes, please provide more details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_172' id='input_3_172' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_173\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_173\"><label class='gfield_label gform-field-label'  >Do you have one (or more) child(ren) under the care of a paediatrician?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_173'>\n\t\t\t<li class='gchoice gchoice_3_173_0'>\n\t\t\t\t<input name='input_173' type='radio' value='No'  id='choice_3_173_0'    \/>\n\t\t\t\t<label for='choice_3_173_0' id='label_3_173_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_173_1'>\n\t\t\t\t<input name='input_173' type='radio' value='Yes'  id='choice_3_173_1'    \/>\n\t\t\t\t<label for='choice_3_173_1' id='label_3_173_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_174\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_174\"><label class='gfield_label gform-field-label' for='input_3_174' >If yes, under which specialist?<\/label><div class='ginput_container ginput_container_text'><input name='input_174' id='input_3_174' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_175\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_175\"><label class='gfield_label gform-field-label' for='input_3_175' >If yes, please provide further details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_175' id='input_3_175' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_176\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_176\"><label class='gfield_label gform-field-label'  >Do you have any children who don&#039;t live with you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_176'>\n\t\t\t<li class='gchoice gchoice_3_176_0'>\n\t\t\t\t<input name='input_176' type='radio' value='No'  id='choice_3_176_0'    \/>\n\t\t\t\t<label for='choice_3_176_0' id='label_3_176_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_176_1'>\n\t\t\t\t<input name='input_176' type='radio' value='Yes'  id='choice_3_176_1'    \/>\n\t\t\t\t<label for='choice_3_176_1' id='label_3_176_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_177\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_177\"><label class='gfield_label gform-field-label' for='input_3_177' >If yes, what is the reason?<\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_3_177' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_178\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_178\"><label class='gfield_label gform-field-label'  >Have you experienced problems with any of your children with regard to health, child support services or parenting?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_178'>\n\t\t\t<li class='gchoice gchoice_3_178_0'>\n\t\t\t\t<input name='input_178' type='radio' value='No'  id='choice_3_178_0'    \/>\n\t\t\t\t<label for='choice_3_178_0' id='label_3_178_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_178_1'>\n\t\t\t\t<input name='input_178' type='radio' value='Yes'  id='choice_3_178_1'    \/>\n\t\t\t\t<label for='choice_3_178_1' id='label_3_178_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_178_2'>\n\t\t\t\t<input name='input_178' type='radio' value='gf_other_choice'  id='choice_3_178_2'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_3_178_other' name='input_178_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_179\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_179\"><label class='gfield_label gform-field-label' for='input_3_179' >If yes, please provide more details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_179' id='input_3_179' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_180\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_180\"><label class='gfield_label gform-field-label'  >Have you ever had a miscarriage?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_180'>\n\t\t\t<li class='gchoice gchoice_3_180_0'>\n\t\t\t\t<input name='input_180' type='radio' value='No'  id='choice_3_180_0'    \/>\n\t\t\t\t<label for='choice_3_180_0' id='label_3_180_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_180_1'>\n\t\t\t\t<input name='input_180' type='radio' value='Yes'  id='choice_3_180_1'    \/>\n\t\t\t\t<label for='choice_3_180_1' id='label_3_180_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_181\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_181\"><label class='gfield_label gform-field-label' for='input_3_181' >If yes, how many?<\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_3_181' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_182\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_182\"><label class='gfield_label gform-field-label'  >Have you ever had an ectopic pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_182'>\n\t\t\t<li class='gchoice gchoice_3_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='No'  id='choice_3_182_0'    \/>\n\t\t\t\t<label for='choice_3_182_0' id='label_3_182_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='Yes'  id='choice_3_182_1'    \/>\n\t\t\t\t<label for='choice_3_182_1' id='label_3_182_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_183\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_183\"><label class='gfield_label gform-field-label'  >Have you ever been diagnosed with an abnormality of your cervix or uterus?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_183'>\n\t\t\t<li class='gchoice gchoice_3_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_3_183_0'    \/>\n\t\t\t\t<label for='choice_3_183_0' id='label_3_183_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='Yes'  id='choice_3_183_1'    \/>\n\t\t\t\t<label for='choice_3_183_1' id='label_3_183_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_184\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_184\"><label class='gfield_label gform-field-label' for='input_3_184' >If yes, please provide further details:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_184' id='input_3_184' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_3_185\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_185\"><label class='gfield_label gform-field-label'  >Have you ever had a cervical smear test?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_185'>\n\t\t\t<li class='gchoice gchoice_3_185_0'>\n\t\t\t\t<input name='input_185' type='radio' value='No'  id='choice_3_185_0'    \/>\n\t\t\t\t<label for='choice_3_185_0' id='label_3_185_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_185_1'>\n\t\t\t\t<input name='input_185' type='radio' value='Yes'  id='choice_3_185_1'    \/>\n\t\t\t\t<label for='choice_3_185_1' id='label_3_185_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_186\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_186\"><label class='gfield_label gform-field-label' for='input_3_186' >If yes, when?<\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_3_186' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_187\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_187\"><label class='gfield_label gform-field-label' for='input_3_187' >What was the result?<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_3_187' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_188\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_188\"><label class='gfield_label gform-field-label'  >Have you ever had a sexually transmitted disease?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_188'>\n\t\t\t<li class='gchoice gchoice_3_188_0'>\n\t\t\t\t<input name='input_188' type='radio' value='No'  id='choice_3_188_0'    \/>\n\t\t\t\t<label for='choice_3_188_0' id='label_3_188_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_188_1'>\n\t\t\t\t<input name='input_188' type='radio' value='Yes'  id='choice_3_188_1'    \/>\n\t\t\t\t<label for='choice_3_188_1' id='label_3_188_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_189\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_189\"><label class='gfield_label gform-field-label' for='input_3_189' >If yes, what was it?<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_3_189' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_190\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_190\"><label class='gfield_label gform-field-label' for='input_3_190' >Who was it treated by?<\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_3_190' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_3_191\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_191\"><label class='gfield_label gform-field-label'  >Have you been circumcised?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_3_191'>\n\t\t\t<li class='gchoice gchoice_3_191_0'>\n\t\t\t\t<input name='input_191' type='radio' value='No'  id='choice_3_191_0'    \/>\n\t\t\t\t<label for='choice_3_191_0' id='label_3_191_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_3_191_1'>\n\t\t\t\t<input name='input_191' type='radio' value='Yes'  id='choice_3_191_1'    \/>\n\t\t\t\t<label for='choice_3_191_1' id='label_3_191_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_192\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_192\"><label class='gfield_label gform-field-label' for='input_3_192' >Please provide any further information\/questions:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_192' id='input_3_192' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_3\"]){return false;}  window[\"gf_submitting_3\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} window[\"gf_submitting_3\"]=true;  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input 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);\n<\/script>","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":66,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"off","_et_pb_old_content":"<h3>Belangrijk!<\/h3>\r\nVoor je aanmelding bij verloskundig centrum Delvi hebben wij persoonlijke gegevens nodig. In verband met de integrale zorg, een nauwe samenwerking met het Reinier de Graaf ziekenhuis, is dit een hele uitgebreide<strong> vragenlijst<\/strong>. Het invullen zal ongeveer 10-15 min in beslag nemen. <strong>Het is van groot belang dat je de lijst zo volledig mogelijk invult;<\/strong>\u00a0indien er onduidelijkheden zijn, kan je contact opnemen of de vraag open laten en stellen tijdens de eerste controle.\r\n\r\n&nbsp;\r\n<h3>Form 2. 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