{"id":1211,"date":"2021-02-17T14:42:33","date_gmt":"2021-02-17T19:42:33","guid":{"rendered":"https:\/\/www.lenoxesthetics.com\/?page_id=1211"},"modified":"2022-02-16T11:36:44","modified_gmt":"2022-02-16T16:36:44","slug":"patient-medical-history-2","status":"publish","type":"page","link":"https:\/\/www.lenoxesthetics.com\/?page_id=1211","title":{"rendered":"Patient Medical History"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1211\" class=\"elementor elementor-1211\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t\t\t<section data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-section elementor-top-section elementor-element elementor-element-78b385ad elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"78b385ad\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-223a5dd6\" data-id=\"223a5dd6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2cb1cf9 elementor-widget elementor-widget-shortcode\" data-id=\"2cb1cf9\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\">\n                <div class='gf_browser_gecko gform_wrapper' id='gform_wrapper_10' style='display:none'><a id='gf_10' class='gform_anchor' ><\/a><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_10' id='gform_10'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1211#gf_10'>\n                        <div class='gform_body'><ul id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below'><li id='field_10_1'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><center><img decoding=\"async\" src=\"https:\/\/www.lenoxesthetics.com\/wp-content\/uploads\/2021\/02\/Screenshot-2021-02-18-at-12.41.01-AM.png\"><\/img><\/center><\/li><li id='field_10_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_2' >Patient<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_10_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_3'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_3' >Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_10_3' type='text' value='' class='datepicker medium dmy datepicker_no_icon'   \/>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_3' class='gform_hidden' value='https:\/\/www.lenoxesthetics.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_10_5'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_5' >LIST OF ALL ALLERGIES TO MEDICATIONS OR SUBSTANCES<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_10_5' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_6'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_6' >LIST OF ALL MEDICATIONS, VITAMINS, OTC PREPARATIONS OR RECREATIONAL DRUGS YOU ARE CURRENTLY TAKING<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_10_6' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_7'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_7' >LIST ANY ARTIFICAL IMPLANTS, PACEMAKER, ECT<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_10_7' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_8'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_8' >IF YOU REQUIRE ANTIBIOTICS PRIOR TO ANY PROCEDURES, PLEASE EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_10_8' type='text' value='' class='large'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_9'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3><b>PERSONAL\/CURRENT\/PAST HEALTH PROBLEMS<\/b><\/h3><\/li><li id='field_10_10'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Cancer<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_10'><li class='gchoice_10_10_0'><input name='input_10' type='radio' value='NO'  id='choice_10_10_0'   onclick='gf_apply_rules(10,[11]);' onkeypress='gf_apply_rules(10,[11]);'  \/><label for='choice_10_10_0' id='label_10_10_0'>NO<\/label><\/li><li class='gchoice_10_10_1'><input name='input_10' type='radio' value='YES'  id='choice_10_10_1'   onclick='gf_apply_rules(10,[11]);' onkeypress='gf_apply_rules(10,[11]);'  \/><label for='choice_10_10_1' id='label_10_10_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_11'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_11' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_10_11' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_12'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Ears\/Nose\/Throat<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_12'><li class='gchoice_10_12_0'><input name='input_12' type='radio' value='NO'  id='choice_10_12_0'   onclick='gf_apply_rules(10,[13]);' onkeypress='gf_apply_rules(10,[13]);'  \/><label for='choice_10_12_0' id='label_10_12_0'>NO<\/label><\/li><li class='gchoice_10_12_1'><input name='input_12' type='radio' value='YES'  id='choice_10_12_1'   onclick='gf_apply_rules(10,[13]);' onkeypress='gf_apply_rules(10,[13]);'  \/><label for='choice_10_12_1' id='label_10_12_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_13'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_13' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_10_13' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_14'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >High blood pressure<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_14'><li class='gchoice_10_14_0'><input name='input_14' type='radio' value='NO'  id='choice_10_14_0'   onclick='gf_apply_rules(10,[15]);' onkeypress='gf_apply_rules(10,[15]);'  \/><label for='choice_10_14_0' id='label_10_14_0'>NO<\/label><\/li><li class='gchoice_10_14_1'><input name='input_14' type='radio' value='YES'  id='choice_10_14_1'   onclick='gf_apply_rules(10,[15]);' onkeypress='gf_apply_rules(10,[15]);'  \/><label for='choice_10_14_1' id='label_10_14_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_15'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_15' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_10_15' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_16'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Lungs<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_16'><li class='gchoice_10_16_0'><input name='input_16' type='radio' value='NO'  id='choice_10_16_0'   onclick='gf_apply_rules(10,[17]);' onkeypress='gf_apply_rules(10,[17]);'  \/><label for='choice_10_16_0' id='label_10_16_0'>NO<\/label><\/li><li class='gchoice_10_16_1'><input name='input_16' type='radio' value='YES'  id='choice_10_16_1'   onclick='gf_apply_rules(10,[17]);' onkeypress='gf_apply_rules(10,[17]);'  \/><label for='choice_10_16_1' id='label_10_16_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_17'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_17' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_10_17' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_18'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Arthritis\/joints<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_18'><li class='gchoice_10_18_0'><input name='input_18' type='radio' value='NO'  id='choice_10_18_0'   onclick='gf_apply_rules(10,[19]);' onkeypress='gf_apply_rules(10,[19]);'  \/><label for='choice_10_18_0' id='label_10_18_0'>NO<\/label><\/li><li class='gchoice_10_18_1'><input name='input_18' type='radio' value='YES'  id='choice_10_18_1'   onclick='gf_apply_rules(10,[19]);' onkeypress='gf_apply_rules(10,[19]);'  \/><label for='choice_10_18_1' id='label_10_18_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_19'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_19' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_10_19' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_20'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Headaches\/seizures<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_20'><li class='gchoice_10_20_0'><input name='input_20' type='radio' value='NO'  id='choice_10_20_0'   onclick='gf_apply_rules(10,[21]);' onkeypress='gf_apply_rules(10,[21]);'  \/><label for='choice_10_20_0' id='label_10_20_0'>NO<\/label><\/li><li class='gchoice_10_20_1'><input name='input_20' type='radio' value='YES'  id='choice_10_20_1'   onclick='gf_apply_rules(10,[21]);' onkeypress='gf_apply_rules(10,[21]);'  \/><label for='choice_10_20_1' id='label_10_20_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_21'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_21' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_10_21' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_22'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Psychological<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_22'><li class='gchoice_10_22_0'><input name='input_22' type='radio' value='NO'  id='choice_10_22_0'   onclick='gf_apply_rules(10,[23]);' onkeypress='gf_apply_rules(10,[23]);'  \/><label for='choice_10_22_0' id='label_10_22_0'>NO<\/label><\/li><li class='gchoice_10_22_1'><input name='input_22' type='radio' value='YES'  id='choice_10_22_1'   onclick='gf_apply_rules(10,[23]);' onkeypress='gf_apply_rules(10,[23]);'  \/><label for='choice_10_22_1' id='label_10_22_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_23'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_23' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_10_23' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_25'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Venereal disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_25'><li class='gchoice_10_25_0'><input name='input_25' type='radio' value='NO'  id='choice_10_25_0'   onclick='gf_apply_rules(10,[26]);' onkeypress='gf_apply_rules(10,[26]);'  \/><label for='choice_10_25_0' id='label_10_25_0'>NO<\/label><\/li><li class='gchoice_10_25_1'><input name='input_25' type='radio' value='YES'  id='choice_10_25_1'   onclick='gf_apply_rules(10,[26]);' onkeypress='gf_apply_rules(10,[26]);'  \/><label for='choice_10_25_1' id='label_10_25_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_26'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_26' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_10_26' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_27'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Eyes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_27'><li class='gchoice_10_27_0'><input name='input_27' type='radio' value='NO'  id='choice_10_27_0'   onclick='gf_apply_rules(10,[28]);' onkeypress='gf_apply_rules(10,[28]);'  \/><label for='choice_10_27_0' id='label_10_27_0'>NO<\/label><\/li><li class='gchoice_10_27_1'><input name='input_27' type='radio' value='YES'  id='choice_10_27_1'   onclick='gf_apply_rules(10,[28]);' onkeypress='gf_apply_rules(10,[28]);'  \/><label for='choice_10_27_1' id='label_10_27_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_28'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_28' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_10_28' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_29'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Heart<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_29'><li class='gchoice_10_29_0'><input name='input_29' type='radio' value='NO'  id='choice_10_29_0'   onclick='gf_apply_rules(10,[30]);' onkeypress='gf_apply_rules(10,[30]);'  \/><label for='choice_10_29_0' id='label_10_29_0'>NO<\/label><\/li><li class='gchoice_10_29_1'><input name='input_29' type='radio' value='YES'  id='choice_10_29_1'   onclick='gf_apply_rules(10,[30]);' onkeypress='gf_apply_rules(10,[30]);'  \/><label for='choice_10_29_1' id='label_10_29_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_30'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_30' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_10_30' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_31'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Liver Disease<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_31'><li class='gchoice_10_31_0'><input name='input_31' type='radio' value='NO'  id='choice_10_31_0'   onclick='gf_apply_rules(10,[32]);' onkeypress='gf_apply_rules(10,[32]);'  \/><label for='choice_10_31_0' id='label_10_31_0'>NO<\/label><\/li><li class='gchoice_10_31_1'><input name='input_31' type='radio' value='YES'  id='choice_10_31_1'   onclick='gf_apply_rules(10,[32]);' onkeypress='gf_apply_rules(10,[32]);'  \/><label for='choice_10_31_1' id='label_10_31_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_32'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_32' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_10_32' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_33'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Stomach\/bowel<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_33'><li class='gchoice_10_33_0'><input name='input_33' type='radio' value='NO'  id='choice_10_33_0'   onclick='gf_apply_rules(10,[34]);' onkeypress='gf_apply_rules(10,[34]);'  \/><label for='choice_10_33_0' id='label_10_33_0'>NO<\/label><\/li><li class='gchoice_10_33_1'><input name='input_33' type='radio' value='YES'  id='choice_10_33_1'   onclick='gf_apply_rules(10,[34]);' onkeypress='gf_apply_rules(10,[34]);'  \/><label for='choice_10_33_1' id='label_10_33_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_34'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_34' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_10_34' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_35'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Kidneys<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_35'><li class='gchoice_10_35_0'><input name='input_35' type='radio' value='NO'  id='choice_10_35_0'   onclick='gf_apply_rules(10,[36]);' onkeypress='gf_apply_rules(10,[36]);'  \/><label for='choice_10_35_0' id='label_10_35_0'>NO<\/label><\/li><li class='gchoice_10_35_1'><input name='input_35' type='radio' value='YES'  id='choice_10_35_1'   onclick='gf_apply_rules(10,[36]);' onkeypress='gf_apply_rules(10,[36]);'  \/><label for='choice_10_35_1' id='label_10_35_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_36'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_36' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_10_36' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_37'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Allergic\/Immunologic<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_37'><li class='gchoice_10_37_0'><input name='input_37' type='radio' value='NO'  id='choice_10_37_0'   onclick='gf_apply_rules(10,[38]);' onkeypress='gf_apply_rules(10,[38]);'  \/><label for='choice_10_37_0' id='label_10_37_0'>NO<\/label><\/li><li class='gchoice_10_37_1'><input name='input_37' type='radio' value='YES'  id='choice_10_37_1'   onclick='gf_apply_rules(10,[38]);' onkeypress='gf_apply_rules(10,[38]);'  \/><label for='choice_10_37_1' id='label_10_37_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_38'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_38' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_10_38' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_39'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Blood\/Bleeding Disorders<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_39'><li class='gchoice_10_39_0'><input name='input_39' type='radio' value='NO'  id='choice_10_39_0'   onclick='gf_apply_rules(10,[40]);' onkeypress='gf_apply_rules(10,[40]);'  \/><label for='choice_10_39_0' id='label_10_39_0'>NO<\/label><\/li><li class='gchoice_10_39_1'><input name='input_39' type='radio' value='YES'  id='choice_10_39_1'   onclick='gf_apply_rules(10,[40]);' onkeypress='gf_apply_rules(10,[40]);'  \/><label for='choice_10_39_1' id='label_10_39_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_40'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_40' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_10_40' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_41'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other (diabetes,lupus,ect.)<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_41'><li class='gchoice_10_41_0'><input name='input_41' type='radio' value='NO'  id='choice_10_41_0'   onclick='gf_apply_rules(10,[42]);' onkeypress='gf_apply_rules(10,[42]);'  \/><label for='choice_10_41_0' id='label_10_41_0'>NO<\/label><\/li><li class='gchoice_10_41_1'><input name='input_41' type='radio' value='YES'  id='choice_10_41_1'   onclick='gf_apply_rules(10,[42]);' onkeypress='gf_apply_rules(10,[42]);'  \/><label for='choice_10_41_1' id='label_10_41_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_42'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_42' >-<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_10_42' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_43'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3><b>MEDICAL HISTORY<\/b><\/h3><\/li><li id='field_10_44'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Allergies<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_44'><li class='gchoice_10_44_0'><input name='input_44' type='radio' value='SELF'  id='choice_10_44_0'     \/><label for='choice_10_44_0' id='label_10_44_0'>SELF<\/label><\/li><li class='gchoice_10_44_1'><input name='input_44' type='radio' value='MOTHER'  id='choice_10_44_1'     \/><label for='choice_10_44_1' id='label_10_44_1'>MOTHER<\/label><\/li><li class='gchoice_10_44_2'><input name='input_44' type='radio' value='FATHER'  id='choice_10_44_2'     \/><label for='choice_10_44_2' id='label_10_44_2'>FATHER<\/label><\/li><li class='gchoice_10_44_3'><input name='input_44' type='radio' value='BLOOD RELATIVE'  id='choice_10_44_3'     \/><label for='choice_10_44_3' id='label_10_44_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_45'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_45' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_10_45' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_46'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Asthma<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_46'><li class='gchoice_10_46_0'><input name='input_46' type='radio' value='SELF'  id='choice_10_46_0'     \/><label for='choice_10_46_0' id='label_10_46_0'>SELF<\/label><\/li><li class='gchoice_10_46_1'><input name='input_46' type='radio' value='MOTHER'  id='choice_10_46_1'     \/><label for='choice_10_46_1' id='label_10_46_1'>MOTHER<\/label><\/li><li class='gchoice_10_46_2'><input name='input_46' type='radio' value='FATHER'  id='choice_10_46_2'     \/><label for='choice_10_46_2' id='label_10_46_2'>FATHER<\/label><\/li><li class='gchoice_10_46_3'><input name='input_46' type='radio' value='BLOOD RELATIVE'  id='choice_10_46_3'     \/><label for='choice_10_46_3' id='label_10_46_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_47'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_47' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_10_47' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_50'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Diabetes<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_50'><li class='gchoice_10_50_0'><input name='input_50' type='radio' value='SELF'  id='choice_10_50_0'     \/><label for='choice_10_50_0' id='label_10_50_0'>SELF<\/label><\/li><li class='gchoice_10_50_1'><input name='input_50' type='radio' value='MOTHER'  id='choice_10_50_1'     \/><label for='choice_10_50_1' id='label_10_50_1'>MOTHER<\/label><\/li><li class='gchoice_10_50_2'><input name='input_50' type='radio' value='FATHER'  id='choice_10_50_2'     \/><label for='choice_10_50_2' id='label_10_50_2'>FATHER<\/label><\/li><li class='gchoice_10_50_3'><input name='input_50' type='radio' value='BLOOD RELATIVE'  id='choice_10_50_3'     \/><label for='choice_10_50_3' id='label_10_50_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_55'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_55' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_10_55' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_49'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Eczema<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_49'><li class='gchoice_10_49_0'><input name='input_49' type='radio' value='SELF'  id='choice_10_49_0'     \/><label for='choice_10_49_0' id='label_10_49_0'>SELF<\/label><\/li><li class='gchoice_10_49_1'><input name='input_49' type='radio' value='MOTHER'  id='choice_10_49_1'     \/><label for='choice_10_49_1' id='label_10_49_1'>MOTHER<\/label><\/li><li class='gchoice_10_49_2'><input name='input_49' type='radio' value='FATHER'  id='choice_10_49_2'     \/><label for='choice_10_49_2' id='label_10_49_2'>FATHER<\/label><\/li><li class='gchoice_10_49_3'><input name='input_49' type='radio' value='BLOOD RELATIVE'  id='choice_10_49_3'     \/><label for='choice_10_49_3' id='label_10_49_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_54'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_54' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_10_54' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_48'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Skin cancer<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_48'><li class='gchoice_10_48_0'><input name='input_48' type='radio' value='SELF'  id='choice_10_48_0'     \/><label for='choice_10_48_0' id='label_10_48_0'>SELF<\/label><\/li><li class='gchoice_10_48_1'><input name='input_48' type='radio' value='MOTHER'  id='choice_10_48_1'     \/><label for='choice_10_48_1' id='label_10_48_1'>MOTHER<\/label><\/li><li class='gchoice_10_48_2'><input name='input_48' type='radio' value='FATHER'  id='choice_10_48_2'     \/><label for='choice_10_48_2' id='label_10_48_2'>FATHER<\/label><\/li><li class='gchoice_10_48_3'><input name='input_48' type='radio' value='BLOOD RELATIVE'  id='choice_10_48_3'     \/><label for='choice_10_48_3' id='label_10_48_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_53'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_53' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_10_53' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_51'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_51'><li class='gchoice_10_51_0'><input name='input_51' type='radio' value='SELF'  id='choice_10_51_0'     \/><label for='choice_10_51_0' id='label_10_51_0'>SELF<\/label><\/li><li class='gchoice_10_51_1'><input name='input_51' type='radio' value='MOTHER'  id='choice_10_51_1'     \/><label for='choice_10_51_1' id='label_10_51_1'>MOTHER<\/label><\/li><li class='gchoice_10_51_2'><input name='input_51' type='radio' value='FATHER'  id='choice_10_51_2'     \/><label for='choice_10_51_2' id='label_10_51_2'>FATHER<\/label><\/li><li class='gchoice_10_51_3'><input name='input_51' type='radio' value='BLOOD RELATIVE'  id='choice_10_51_3'     \/><label for='choice_10_51_3' id='label_10_51_3'>BLOOD RELATIVE<\/label><\/li><\/ul><\/div><\/li><li id='field_10_52'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_10_52' >EXPLAIN<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_10_52' type='text' value='' class='medium'      aria-invalid=\"false\" \/><\/div><\/li><li id='field_10_56'  class='gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible' ><h3><b>TO BE COMPLETED BY ALL WOMEN<\/b><\/h3><\/li><li id='field_10_57'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you nursing or pregnant?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_57'><li class='gchoice_10_57_0'><input name='input_57' type='radio' value='NO'  id='choice_10_57_0'     \/><label for='choice_10_57_0' id='label_10_57_0'>NO<\/label><\/li><li class='gchoice_10_57_1'><input name='input_57' type='radio' value='YES'  id='choice_10_57_1'     \/><label for='choice_10_57_1' id='label_10_57_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_58'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you currently planning a pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_10_58'><li class='gchoice_10_58_0'><input name='input_58' type='radio' value='NO'  id='choice_10_58_0'     \/><label for='choice_10_58_0' id='label_10_58_0'>NO<\/label><\/li><li class='gchoice_10_58_1'><input name='input_58' type='radio' value='YES'  id='choice_10_58_1'     \/><label for='choice_10_58_1' id='label_10_58_1'>YES<\/label><\/li><\/ul><\/div><\/li><li id='field_10_59'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you taking birth control pills?<\/label><div class='ginput_container 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